Denver Health Medical Plan (DHMP) Complaint and Appeal Form

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DHMP PLAN TYPE (PLEASE CHECK ONE)*

Elevate Exchange Plans





Colorado Option


Elevate Medicare Advantage

Elevate Child Health Plan Plus
Elevate Medicaid Choice
DHHA

 

Please fill out the form below. Use the person’s information that the complaint or appeal is being submitted for:

 

 

 

 

 

If you are sending this form in for someone else:

You will need to upload an Appointment of Representative (AOR) form with this complaint or appeal.

Without an Appointment of Representative Form, we will not be able to process your complaint or appeal. Exception: physicians acting for their Medicare member patients do not need to send in the CMS 1696 AOR form.

 

 

 

 

Relationship to Member





NOTE: Choosing 'Provider/Physician' above means the physician and/or provider is acting on the member's behalf, with the member's knowledge and approval.

SECTION A: COMPLAINT

If this is for a complaint, please tell us about the issue in the box below. If you are filing an appeal, please go to Section B. Have dates of service and staff names, if applicable. You may upload more pages and/or supporting documentation, if needed.

SECTION B: APPEAL

For an appeal to a previously denied service or claim, please fill out the questions below.

Is this in regard to a denied claim?

If yes, please give us:

 

 

 

Or is this in regard to a denied medical visit or treatment?

 

Please give us the reason and a brief description of your appeal. You may upload more pages and/or supporting documentation, if needed.

 

Member Signature

 

Authorized Representative Signature

 

ATTACH SUPPORTING DOCUMENTATION:


We can help you fill out this form. If you have any questions, please call the DHMP Complaint and Appeal Department. We can be reached at 303-602-2261, 8 a.m. - 5 p.m. Monday through Friday. If we cannot take your call, leave a message and we will return your call within 48 business hours.

DOWNLOAD FORM DATA (PRIOR TO SUBMISSION):

If you would like to download the data you have entered in this form, click on the 'Download Form Data' button below. A CSV file that contains the data you are providing in this form will be downloaded to your computer. You need to click the 'Download Form Data' button after you have completed the form but before you click on the 'Submit Form' button.

 

SUBMIT FORM:

You must complete all required fields prior to submission. To ensure files and data are successfully submitted, do not close this window until you see a 'Thank You' confirmation page.

*Field is required

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