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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
Employer Resources
>
Freedom Hybrid - Employer Resources
HSA Freedom Hybrid - Employer Resources
Freedom Traditional - Employer Resources
Cost Saver Plan - Employer Resources
PPO - Employer Resources
Freedom Essentials - Employer Resources
MEC - Employer Resources
Apex MEC - Employer Resources
Community Health Plan - Employer Resources
Prime-Fundamental Care - Employer Resources
Vault PPO - Employer Resources
Vault RBP - Employer Resources
EBA Newsletter
Members
Member Resources
HealthCare Assistant
HealthChoices
Self-Service Login
Find A Provider
Prescription Benefits
Telehealth
Lab Program
Abenity Discounts
Member Download Forms
>
Appeals
Member FAQs
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
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>
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Contact Us