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Subject: Member or Provider Appeals Process Effective Date
Appeal Form] Following an Adverse Benefit determination for a Pre-service, Concurrent or Urgent claim, the appellant can request a First Level Internal Appeal
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Provider Appeal Form
Please submit this request by visiting our Provider Portal, fax to 315-234-9812- Attention: Appeals Grievances Department or by mail to Molina Healthcare
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Member Appeal Form
Timeframe to request an appeal: This form must be completed and received at Blue Cross and Blue Shield of North Carolina. (Blue Cross NC) within 180 days of the
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