EXTERNAL REVIEW

External Review Form

Provider Information

Provider First Name *

Provider Last Name *

Provider DEA Number *

Provider Email *

Provider Phone *

Provider Fax *

Member First Name *

Member Last Name *

Member Date of Birth *

Member Employer Employee ID

Member Dependent Number

Member Social Security # (9 digits, No dash or Space) *

Member Email *

Member Phone *

Enter at least 10 digits

Member Address Line 1 *

Member Address Line 2

Member City *

Member State *

Member ZIP Code *

Drug Name *

Quantity *

Day Supply *

Weight in Pounds *

Range: 50-800 lbs

Height in Inches *

Range: 36-96 inches (3-8 ft)

BMI (Body Mass Index) *

Does the patient have Hyperlipidemia, Hypertension, Obstructive Sleep Apnea, Cardiovascular disease, Type 2 diabetes, Nonalcoholic fatty liver disease/MASH, Osteoarthritis of knee/hip/back, Moderate/Severe Asthma or Reactive airway disease? *

Has the patient completed 3 health coaching sessions within the past 6 months? *

Has the patient maintained 5% weight loss in baseline body weight after 6 months on medication? *

Please describe why you disagree with the denial decision? (you may attach additional information, such as a physician’s letter, bills, medical records, or other documents to support your claim) *

Upload Additional Information (Optional)

Upload additional information such as progress notes indicating height, weight, comorbidities (if any). Accepted: PDF, JPG, PNG.

Click to upload files

Please read the following information prior to completing this form.

Only complete this appeal form if you have: (1) completed the First-Time Questionnaire or Renewal Questionnaire and received a Denial Decision, and (2) submitted two Internal Appeal Forms, each resulting in a Denial Decision.