How to Appeal a Claim

If you aren’t satisfied with our decision about your claim for benefits, you have the right to file an appeal. If you decide to appeal, you must file a written appeal and send it to TeamCare within 180 days of the original benefit decision.

To file an appeal of a claim or benefits decision, follow the steps below.

Why Was My Claim Denied?

There are several reasons why a claim may be denied. It’s possible that the claim was denied because it was for a service not covered by TeamCare, or for a treatment that was deemed as not medically necessary. A claim may also be denied because an out-of-network provider was used, or because another insurer should have been billed first. Your Explanation of Benefits includes a reason why your claim was denied.

How to File

You may file an appeal by printing and completing the form that is available on the Claim Appeals page, or by writing your own letter.

Write a letter


Appealing With Our Form

If you’d like to appeal your claim using our appeals form, you can download and print a form by logging in to your MyTeamCare account and going to Claim Appeals. Simply fill out the form, and send it back to us.

Appealing With a Letter

If you are filing your appeal by letter, be sure your letter contains:

  1. The member’s name and address
  2. The member’s ID number
  3. Claim number
  4. The patient’s name
  5. The patient’s relationship to the member
  6. Date of loss
  7. The EXACT reason you are dissatisfied with our decision

What to Provide

Whether you’re filing an appeal using our form or a letter you wrote, be sure to submit a copy of our denial letter or Explanation of Benefits. We also recommend submitting any additional information that you can to support your appeal, such as medical records to support a claim that was deemed not medically necessary. The more information you provide us, the easier time we’ll have processing your appeal.

If you have questions, please send a secure message through the Message Center or call a Benefits Specialist at 1-800-TEAMCARE (1-800-832-6227).

Filing Your Appeal

You can send your completed appeals form or letter, as well as any questions or requests about your appeal, via the Message Center, or to:

Research & Correspondence Department
TeamCare, A Central States Health Plan
PO Box 5126
Des Plaines, Illinois 60017-5126
Fax: 1-847-518-9794

Next Steps

After you submit your appeal, we begin our two-step appeals process. If your first appeal is denied, you have the right to file a second and final appeal. If you choose to file a second appeal, you must file it within 180 days from the day you are notified that your first appeal was denied. 

If your second and final appeal is denied, you have the right to bring suit under Section 502(a) of ERISA in an attempt to recover benefits due under the terms of your plan, enforce rights under the terms of your plan, or to clarify rights to future benefits under the terms of your plan. 

An internal rule or guideline may have been used to make your benefit determination. In that case, a copy of that rule or guideline will be provided free of charge to you upon written request. If your benefit decision was made because the treatment was determined to be not medically necessary, or an experimental treatment, an explanation of the scientific or clinical judgment used in the decision will be provided to you free of charge upon written request.