Online Member Request, Appeal or Complaint Form

Please fill out the form below to request a coverage decision, appeal, or to file a formal complaint for any part of care or service you had from OneCare. Click “Submit” to make sure your information is right before you submit your form. If you have any problems filling out this form, please call OneCare Customer Service Department at 1-877-412-2734. TDD/TTY users can call 1-800-735-2929.

If you wish to have someone represent you, other than your doctor, you must submit an Appointment of Representative Form or a legal document authorizing a representative to act on your behalf.

* = Mandatory Fields

Date of Complaint:

Thursday, April 18, 2024

* Name of person filling out this form:

*Date of Incident/Denial:

* Relationship:

* Member First Name:

MI:

* Member Last Name:

* Contact/Message Number:

* Current Home Address:

* City:

* Zip Code:

* Member ID Number:

* Member's Date of Birth:

* Do you have a denial letter signed by a doctor?

Yes

Description of the concern or issue: (Briefly describe the reason for your appeal, complaint, or request, including requests for exception of our drug coverage. Include drug name(s) or service denied, date, and details):

How have you tried to resolve this problem?

Please take some time to review this form to make any changes or add more information. If you have any problems filling out this form, please call OneCare Customer Service Department at 1-877-412-2734.

Thank you for taking time to share your concerns with OneCare. Please read your OneCare Evidence of Coverage for more information on your member rights, health coverage and available services.

OneCare Customer Service
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To file a complaint with Medicare, click on the following link to complete a complaint form on the Medicare website: Medicare Complaint Form.

H5433_24WEB001_2024_A (Accepted 9/19/2023)

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