Appeal Form

If you're a Salia member and are unable to resolve your concern through Customer Service, we have a formal grievance and appeals process. You can use this form to start that process.

Salia Healthcare will accept your request for an appeal when the request is submitted within 180 days from the initial denial notification. If more than 180 days have passed since you were notified, and you still have a question, please call your Customer Service Center using the number on the back of your ID card.

Appeal Form

Subscriber / Patient Information

Subscriber Name

First Name *

Last Name *

Member ID

Phone Number

Relationship to Subscriber

Self

Spouse

Dependent

Patient Name

First Name *

Last Name *

Physical Address

City

State/Province

Zip/Postal

Is your mailing address the same as your physical address?

Yes

Mailing Address

City

State/Province

Zip/Postal

Appeal Request

You can appeal a post-service claim.
A post-service claim is a claim you or your provider submitted for payment for a service or item you think is covered.

Have you already received the service(s)?

Yes

Provider Name

Type of Service

Location of Service

Name of Ordering Provider

Date of Service

Total Charge Amount

Reason for Appeal

Tell us why you're submitting an appeal

If you are human, leave this field blank.

Appeal Form

Subscriber / Patient Information

Subscriber Name

Patient Name

Appeal Request

Reason for Appeal

Offices

Links

LinkedIn

Contracting Point of Contact

Contracting Point of Contact

Appeal Form

Subscriber / Patient Information

Subscriber Name

Patient Name

Appeal Request

Reason for Appeal

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