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Important information you need to know if you are unhappy with the steps we and/or your doctor took for your request, let. Attach copies of any records you wish to submit. Please include a copy of the eob with the appeal and any supporting documentation. Health care authority (hca) board of appeals review judge decision how do i ask for (file) an appeal?
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Web contact us select your state from the menu below: State administrative hearing step 3: Fill out this form completely. Box 165089 irving, tx 75016 # of pages (including caf cover sheet) date:
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We want to know about your problems and complaints. Member healthcare provider denied service: Box 165089 irving, tx 75016 member grievance/appeal request form molina healthcare recognizes the fact that members may not always be satisfied with the care and services provided by our contracted doctors, hospitals and other providers. Web instructions for filing a complaint/appeal: