Email Provider Relations

You may use this form to submit an email to MCNA's Provider Relations team. Please provide as much information as possible to help us determine how best to assist you.

Submit an Appeal

This form is not to be used for initial claim submission or claims adjustments (such as corrected claims). Complete and submit this form to MCNA, along with all documents that support your appeal, within the time frame indicated from the date of MCNA's notice of denial.

Contact and Provider Information

Your Full Name *

Your Email Address *

Your Phone Number

Your Role at the Office *

Office Name *

Provider's Full Name *

Provider's NPI Number *

Provider's MCNA ID

Member and Claim Information

Member's Full Name

Member's MCNA ID Number

Member's Date of Birth

Claim Number(s)

Date of Service

Appeal Information

Appeal Level

Please select the appropriate level for this appeal. Note that Second Level Appeals are for Medicaid Medical Necessity denials only.

First Level AppealSecond Level Appeal

Appeal Reason

Below are reasons you can appeal a claim that has been denied. You may attach a detailed explanation for this appeal.

Untimely FilingNo Authorization ObtainedNon-Covered BenefitsMedical NecessityOther Reason (Please describe in notes field below)

Supporting Documentation

Please select all that apply and include the documents as file attachments below.

Chart Notes, Narratives, Models, RadiographsProof of Original SubmissionCopy of Remittance Advice (RA)Other Documentation

Please attach any supporting documents for this appeal. If you are submitting a bulk appeal, please attach a spreadsheet that includes the Member Names, Claim Numbers, Denial Reasons, and Dates of Service for each claim. Please also specify the reason(s) for the appeals.

File Attachments for this Appeal

You may provide any additional notes for our team.

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