Authorized Representative Designation Form (PDF 34.22 KB)
Claim Reconsideration Request Form (PDF 776.02 KB)
FAQ - Provider Claim Corrections Reconsiderations (PDF 109.66 KB)
Provider Grievance Appeal Form (PDF 43.9 KB)
Reconsideration Appeal and State Fair Hearing Flowchart (PDF 139.8 KB)
For additional information about the Appeals, Grievances and State Fair Hearing
Process, click here.