Remember this form is to be used ONLY when you believe C2C Solutions has overlooked documentation submitted and did not process your appeal correctly.
Complete the entire form, leaving out any HIPAA information.
Do not append any documents with the form.
If you failed to include any documents, C2C Solutions cannot amend their decision on the Level 2 appeal. This is where you would have to appeal to the next level with the ALJ.
The form can be faxed to 904-224-2760 or mailed to:
PO Box 44163
Jacksonville FL 32231
The Reimbursement Team