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Marketplace Appeal Request EAII Form Marketplace Appeal Request EAII Form (06 2019)

Marketplace Appeal Request EAII Form Marketplace Appeal Request EAII Form (06 2019)-2025

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The document is a Marketplace Appeal Request Form designed for individuals to appeal decisions made by the Health Insurance Marketplace regarding their eligibility for financial assistance. It outlines the steps required to complete the appeal, including providing personal information, reasons for the appeal, necessary documentation to support the claim, and obtaining signatures from all tax filers involved. The form also includes options for expedited appeals due to health reasons and allows for the designation of an authorized representative.

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Versions	Form popularity	Fillable & printable
2021	4.9 Satisfied (53 Votes)
2019	4.4 Satisfied (218 Votes)
2019	4.4 Satisfied (34 Votes)
2015	4.2 Satisfied (40 Votes)
2014	4 Satisfied (53 Votes)
2013	4.2 Satisfied (40 Votes)

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How to fill marketplace appeal form?

To fill out this Marketplace Appeal Request Form (PDF), youll need to download it onto your computer first. Step 1: Download the Marketplace Appeal Request Form. Step 2: Save the form on your computer. Step 3: Open the form and fill it out. Step 4: Submit the form by mail or fax.

What is the phone number for the Marketplace appeals center?

Appeals Center at 1-855-231-1751, Monday Friday from 7:00 a.m. 8:30 p.m. Eastern time (ET). TTY users can call 711. at 1-800-318-2596.

Can consumers file an appeal of a marketplace eligibility determination?

If you dont agree with a decision made by the Marketplace, you generally have 90 days from the date of your Eligibility Notice to ask for an appeal.

How to dispute a 1095a?

If you find errors on your 1095-A Form, you can call Covered CA at 1-800-300-1506 to correct it, or you can file a 1095-A Dispute Form. It can take up to 60 days for Covered CA to respond with a corrected form.

How do I appeal a marketplace decision?

Appeals Center at 1-855-231-1751, Monday Friday from 7:00 a.m. 8:30 p.m. Eastern time (ET). TTY users can call 711. at 1-800-318-2596. TTY users can call 1-855-889-4325.