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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.
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  • Home
  • Employers
    • Self-Service Login
    • Prescription Benefits
    • Lab Program
    • Abenity Discounts
    • EBA Newsletter
    • Downloadable Forms
  • Members
    • Member Resources >
      • Explanation of Benefits
      • 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-Preventive Minimum Essential Coverage >
        • Member-Spanish Preventive 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
    • Benefit Extras >
      • Abenity 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
    • Plans >
      • Level Funding >
        • Freedom Plan >
          • Hybrid
          • Traditional
          • Essentials
        • PPO
        • Cost Saver Plan
        • Preventive Minimum Essential Coverage
        • Direct Primary Care >
          • DPC Directory
      • Dental Design
      • Pivot Health Individual Plans >
        • Short Term Medical
        • Fixed Benefit
        • Brilliant Dental
      • Premium Only Plan
    • Self-Service Login
    • Download Forms - Agents
    • Product Availability
    • Training Webinars
    • Agent FAQs
  • Provider
    • Provider Verification
    • DPC & Benefit Plans
  • About Us
    • History
    • Testimonials
    • Blog
    • Newsroom >
      • Allied Logos
  • Contact Us