Allied National
  • Home
  • Employers
    • Self-Service Login
    • Prescription Benefits
    • Lab Program
    • Allied Member Discounts
    • EBA Newsletter
    • Downloadable Forms
  • Members
    • Member Resources for Funding Advantage >
      • Explanation of Benefits for Funding Advantage Members
      • Member FAQs
      • Member-Hybrid >
        • Member-Hybrid-Plan-Info
        • Member-Spanish-Hybrid-Plan-Info
      • Member-Traditional >
        • Member-Traditional-Plan-Info
        • Member-Spanish Traditional-Plan-Info
      • Member-Essentials >
        • Member-Essentials-Plan-Info
        • Member-Spanish Essentials-Plan-Info
      • Member-PPO >
        • Member-PPO-Plan-Info
        • Member-Spanish-PPO-Plan-Info
      • Member-Cost Saver >
        • Member-Cost Saver-Info
        • Member-Spanish-Cost Saver-Info
      • Member-Minimum Essential Coverage >
        • Member-Spanish Minimum Essential Coverage
      • Member - Community Health Plan >
        • Member-Community Health-Plan-Info
      • Member-H&H PLan >
        • Member-H&H Plan-Info
      • Member-Vault PPO Resources >
        • Member-Vault-PPO-Plan-Info
      • Member-Vault RBP >
        • Member-Vault RBP-Plan-Info
      • Member-Fundamental Care
      • Member-Fundamental Care Value Plan
    • Benefit Extras >
      • Allied Member Discounts
      • Elite Experience Team
      • HealthCare Assistant
      • HealthChoices
      • Lab Program
      • Telehealth
    • Self-Service Login >
      • Self -Service Site Info
    • Find A Provider
    • Prescription Benefits
    • Member Download Forms >
      • Appeals
  • Agents
    • Agent Edge
    • Group Submissions
    • Plans >
      • Level Funding Group >
        • Freedom Plan >
          • Hybrid
          • Traditional
          • Essentials
        • PPO
        • Cost Saver Plan
        • Minimum Essential Coverage
        • Direct Primary Care
      • Dental Design Group
      • Premium Only Plan Group
      • Individual Plans
    • Self-Service Login
    • Download Forms - Agents
    • Product Availability
    • Training Webinars
    • Agent FAQs
    • Bulletin (Agent)
  • Provider
    • Provider Verification
    • DPC & Benefit Plans
  • About Us
    • History
    • Testimonials
    • Blog
    • Newsroom >
      • Allied Logos
  • Contact Us

Allied

Self-Funded Claim Appeal Notice
Dental Universal Appeal Notice

Federal

Dental Claim Form

State

If you are interested in filing a claim appeal, use the specific forms for your state, if listed. If your state is not listed, please use the ERISA form below to file your appeal.

ERISA Form
Notice of State Claim Appeal Rights

Delaware

Delaware External Claim Review Information
​ERISA Form
Notice of State Claim Appeal Rights

Georgia

Georgia External, Independent Claim Review Information
ERISA Form
Notice of State Claim Appeal Rights

Iowa

Iowa External Claim Review Information
ERISA Form
Notice of State Claim Appeal Rights

Kansas

Kansas External, Independent Claim Review Information
ERISA Form
Notice of State Claim Appeal Rights

Missouri

Missouri External Claim Review Information
ERISA Form
Notice of State Claim Appeal Rights

Nebraska

Nebraska External Claim Review Information
ERISA Form
Notice of State Claim Appeal Rights

Ohio

Ohio External Claim Review Information
ERISA Form
Notice of State Claim Appeal Rights

South Carolina

South Carolina External Claim Review Information
Medical Records Release
ERISA Form
Notice of State Claim Appeal Rights

Texas

Texas External Claim Review Information
Request for a Review by an Independent Review Organization
ERISA Form
Notice of State Claim Appeal Rights

Virginia

Virginia External Review Form
ERISA Form
Notice of State Claim Appeal Rights
If you are unable to find what you're looking for, please contact Allied Client Services.
Site Disclaimer  l  Privacy Policy  l  Insurance Terms
 California Consumer Privacy Act and Notice at Collection.
© 2022 Allied National, LLC. All Rights Reserved.
  • Home
  • Employers
    • Self-Service Login
    • Prescription Benefits
    • Lab Program
    • Allied Member Discounts
    • EBA Newsletter
    • Downloadable Forms
  • Members
    • Member Resources for Funding Advantage >
      • Explanation of Benefits for Funding Advantage Members
      • Member FAQs
      • Member-Hybrid >
        • Member-Hybrid-Plan-Info
        • Member-Spanish-Hybrid-Plan-Info
      • Member-Traditional >
        • Member-Traditional-Plan-Info
        • Member-Spanish Traditional-Plan-Info
      • Member-Essentials >
        • Member-Essentials-Plan-Info
        • Member-Spanish Essentials-Plan-Info
      • Member-PPO >
        • Member-PPO-Plan-Info
        • Member-Spanish-PPO-Plan-Info
      • Member-Cost Saver >
        • Member-Cost Saver-Info
        • Member-Spanish-Cost Saver-Info
      • Member-Minimum Essential Coverage >
        • Member-Spanish Minimum Essential Coverage
      • Member - Community Health Plan >
        • Member-Community Health-Plan-Info
      • Member-H&H PLan >
        • Member-H&H Plan-Info
      • Member-Vault PPO Resources >
        • Member-Vault-PPO-Plan-Info
      • Member-Vault RBP >
        • Member-Vault RBP-Plan-Info
      • Member-Fundamental Care
      • Member-Fundamental Care Value Plan
    • Benefit Extras >
      • Allied Member Discounts
      • Elite Experience Team
      • HealthCare Assistant
      • HealthChoices
      • Lab Program
      • Telehealth
    • Self-Service Login >
      • Self -Service Site Info
    • Find A Provider
    • Prescription Benefits
    • Member Download Forms >
      • Appeals
  • Agents
    • Agent Edge
    • Group Submissions
    • Plans >
      • Level Funding Group >
        • Freedom Plan >
          • Hybrid
          • Traditional
          • Essentials
        • PPO
        • Cost Saver Plan
        • Minimum Essential Coverage
        • Direct Primary Care
      • Dental Design Group
      • Premium Only Plan Group
      • Individual Plans
    • Self-Service Login
    • Download Forms - Agents
    • Product Availability
    • Training Webinars
    • Agent FAQs
    • Bulletin (Agent)
  • Provider
    • Provider Verification
    • DPC & Benefit Plans
  • About Us
    • History
    • Testimonials
    • Blog
    • Newsroom >
      • Allied Logos
  • Contact Us