Rejection Claim Submission Form
From *
Enter Practice Name
Key *
Enter CoverMyMeds key here
Rejection Claim *
Patient Name, DOB, Address, Phone | Medication Name, Quantity, Days Supply, NDC
Prescriber: Name, NPI, Address, Phone, Fax | Insurance: Plan, Member ID, Group, BIN, PCN
Primary Diagnosis *
ICD-10 Code (e.g. L72.3 or G43.709)
Secondary Diagnosis
Optional secondary diagnosis code
Is the medication requested intended as an initial therapy or a continuation of therapy?
Please Select
Initial Therapy
Continuation Of Therapy
Select one option only
Attach File(s)
Notes
Any additional comments (optional)
Submit
