REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE …
EVOLENT HEALTH Appeal or Grievance Member Services Intake RequestPlease fax to Evolent Appeals and Grievance Dept : 1-855-435-8762 Call Receipt Cut Log: Click here to enter text.Date: Click here to enter a date.Time of Call: Click here to enter text.Member Services Representative Name: Click here to enter text.Phone: Click here to enter text.Caller InformationCaller Name: Click here to enter text.Phone: Click here to enter text.Relationship to Member: Click here to enter text.Address (N/A if caller is member): Click here to enter text.City: Click here to enter text.State: Click here to enter text.Zip: Click here to enter text.Member Name: Click here to enter text.Member Phone: Click here to enter text.Member ID: Click here to enter text.Plan Name: Click here to enter text.AOR or POA on file: Yes ? No ? NA ?Date AOR received: Click here to enter text.Details of CallExpedited Request ? Standard Request ?Appeal ?Grievance ?Date(s) of Service (if applicable): Click here to enter a date.Provider Name (if applicable): Click here to enter text.Vendor issue: N/A ? Avesis ? Magellan ? Optum ?Detailed account of Caller’s issues: Click here to enter text.Verified accuracy of request and intent of caller (Insert initials here) : Click here to enter text. ................
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