Claim Appeals for Non-Participating Providers – Doctors HealthCare Plans, Inc.

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Claim Appeals for Non-Participating Providers

Non-Participating providers may submit a Claim Appeal within sixty five (65) calendar days from the date of the corresponding Remittance Advice. Claim Appeals submitted past sixty five (65) days from the date of the corresponding Remittance Advice will be considered a late filing and may be dismissed if good cause is not established.

Supporting documentation must include a signed waiver of liability (WOL) (click here for form) as required by the Centers for Medicare and Medicaid Services (CMS), the Remittance Advice and medical records.

Claim Appeals can also be mailed to:

Doctors HealthCare Plans, Inc.
Attn: Grievances & Appeals Unit
2020 Ponce de Leon Blvd., PH 1
Coral Gables, FL 33134

CLAIM INFORMATION

Claim ID *

Billed Amount *

Date of Service *

MEMBER INFORMATION

Member Name *

First

Last

Member ID *

Date of Birth *

PROVIDER INFORMATION

Provider Name *

Tax ID *

Contact Name *

Fax *

Telephone *

Ext Number

Email *

REASON FOR REQUESTING REVIEW

Appeal Type *

REQUIRED DOCUMENTATION

Remittance Advice *

Drag & Drop Files, Choose Files to Upload

The file formats you can upload are .tiff, .jpg, .png, .doc, and .pdf. If attachment is over 30MB, please split the file to conform to size limit.

Waiver of Liability (WoL) *

Drag & Drop Files, Choose Files to Upload

The file formats you can upload are .tiff, .jpg, .png, .doc, and .pdf. If attachment is over 30MB, please split the file to conform to size limit.

Captcha Security Question *

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Last Updated: 07/01/2025
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