Claim Appeals for Non-Participating Providers – Doctors HealthCare Plans, Inc.

Your Health, Our Commitment

2020 Ponce de Leon Blvd, Suite PH 1, Coral Gables, FL 33134

Claim Appeals for Non-Participating Providers

Non-Participating providers may submit a Claim Appeal within sixty (60) calendar days from the date of the corresponding Remittance Advice. Claim Appeals submitted past sixty (60) days from the date of the corresponding Remittance Advice will be considered a late filing and may be dismissed if good cause is not established.

Supporting documentation must include a signed waiver of liability (WoL) (click here for form) as required by the Centers for Medicare and Medicaid Services (CMS), the Remittance Advice and medical records.

Claim Appeals can also be mailed to:

Doctors HealthCare Plans, Inc.
Attn: Grievances & Appeals Unit
2020 Ponce de Leon Blvd., PH 1
Coral Gables, FL 33134

CLAIM INFORMATION

Claim ID *

Billed Amount *

Date of Service *

MEMBER INFORMATION

Member Name *

First

Last

Member ID *

Date of Birth *

PROVIDER INFORMATION

Provider Name *

Tax ID *

Contact Name *

Fax *

Telephone *

Ext Number

Email *

REASON FOR REQUESTING REVIEW

Appeal Type *

REQUIRED DOCUMENTATION

Remittance Advice *

Click or drag a file to this area to upload.

The file formats you can upload are .tiff, .jpg, .png, .doc, and .pdf. If attachment is over 25MB, please split the file to conform to size limit.

Waiver of Liability (WoL) *

Click or drag a file to this area to upload.

The file formats you can upload are .tiff, .jpg, .png, .doc, and .pdf. If attachment is over 25MB, please split the file to conform to size limit.

Captcha Security Question *

=

Last Updated: 10/27/2021
H4140_APPEALSPROVCLWS_C

Mailing Address: 2020 Ponce de Leon Blvd, PH1, Coral Gables Florida, 33134

Please call Member Services at 786-460-3427 or 833-342-7463 (TTY: 711), 7 days a week 8 a.m. to 8 p.m.

Discrimination is against the law: Doctors HealthCare Plans, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex or religion.
See our Non-Discrimination Notice Requirements (Section 1557 of the Affordable Care Act of 2010) with the Multi-language interpreter service.

Non-Discrimination Notice and Multi-Language Interpreter Service | Aviso Contra la Discriminaciòn y Servicio de Intêrprete Multilingüe
Member Rights and Responsibilities | Derechos y responsabilidades de los asociados
Interoperability APIs | Interoperabilidad API

Important Links and Information: AHCA | HEDIS & NCQA | Privacy Notice | Medicare Complaint Form | Medicare Ombudsman

Doctors HealthCare Plans, Inc. is an HMO with a Medicare contract. Enrollment in Doctors HealthCare depends on contract renewal.

>