Blue Card Appeal Request Form

This form is to be used to request a reconsideration of a previously adjudicated claim but there is no additional or corrected data to be submitted.

Date of Appeal Request:

Please enter Blue KC Claim ID Number(s): *:

Please explain the reason for the Appeal Request (please note: Appeals are for medical necessity only. All other inquiries for denials must be submitted on an inquiry form)*

Please explain the supporting documentation your are submitting as part of this appeal. *

Please attach supporting documentation:*

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

• Checking this box will send a copy of your form to the email address provided.

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