ASHLink - Appeals Other

Provider Appeals

You may appeal any non-approved or partially approved service or any non-payment of a claim. All appeals must be submitted within 180 days after the notice of partial or non-approval by ASH.

Please complete the online form below to submit your appeal electronically to ASH. You may print a PDF version of the Appeals Form to fax or mail directly to ASH.

*Required Fields

Provider Information:

First name:

Last name:

Clinic Street Address:

City:

State:

Zip Code:

Phone:

Member/Insured Information:

First name:

Last name:

Member/Insured ID#:

Date Of Birth:

* Enter date of birth

Health Plan:

(optional)

Type of Appeal:

Please check which type of appeal you are submitting: *

Clinical (ie. x-ray approval, office visit approval, etc.)

Administrative (i.e. timelines, member eligibility, etc.)

Reason for Appeal/Clinical Rationale: *
Please explain, in detail, your rationale for this appeal.

If you have supporting documentation that you would like to submit along with your on-line appeal request, you may fax the documentation to the attention of the ASH Appeals Coordinator at 877.404.2746, toll free. You will receive a confirmation number when you have completed this submission. For any supporting documentation that you are submitting, please list this confirmation number at the top of each page. These documents will then be included as part of your appeal review.