Your Denied Claim
This is your claim data, not your personal information. It is used to draft your appeal and is never linked to your identity.
Procedure codes from your denial letter or EOB.
Diagnosis codes if listed. Leave blank if not shown.
Leave end date blank if service was on a single day.
Look for "you have the right to appeal within..." on your denial letter or EOB — often 180 days from the EOB date.
Open your denial letter or EOB. Look for the section titled "Reason for Denial," "Explanation of Determination," or similar. Copy and paste it here.
Your Information
Your name, date of birth, and insurance IDs are encrypted before they leave your device. They are stored separately from your claim data and only accessed by our team during appeal preparation and transmission.
Usually printed on the front of your insurance card.
Used to send a verification code when you check your case status.
Used for transmission confirmation.
Legal Authorization & Signature
Please review the following documents before signing. Your signature on this step authorizes Remedy Support to access your claim records and act as your administrative representative under HIPAA.
Before submitting your claim, please review:
HIPAA Authorization & Limited Power of Attorney
I, the undersigned, hereby authorize Remedy Support ("Representative") to act as my authorized representative and limited attorney-in-fact for the sole purpose of filing, tracking, and managing an administrative appeal of the insurance claim denial identified in this intake form.
Pursuant to 45 CFR §164.508 (HIPAA Privacy Rule), I authorize my insurance carrier and its affiliates to release to my Representative all health information, claim records, Explanation of Benefits documents, and correspondence reasonably necessary to evaluate, draft, and submit an administrative appeal on my behalf.
This authorization is limited to the specific denied claim identified in this form. It does not grant authority to make binding legal decisions, initiate litigation, or access medical records beyond what is directly related to the identified claim. This authorization may be revoked at any time by contacting Remedy Support in writing and will be effective upon receipt.
I understand that my personal health information will be used solely to draft and file the administrative appeal, will be encrypted at rest, and will not be sold, shared for marketing, or disclosed to any party beyond those necessary to complete the appeal.
I acknowledge that I am the patient or the legal guardian or authorized representative of the patient named in this form.
Your signature is legally equivalent to a handwritten signature. By adopting it, you authorize Remedy Support to securely use it on HIPAA authorizations and other documents reasonably necessary to prepare and submit your appeal. Your signature is encrypted, stored securely, and used only for authorized appeal activities.
Authorized Representative Agreement
This is a Limited Power of Attorney granting Remedy Support authority to act as your authorized administrative representative with your insurance carrier. Please read the full agreement and sign below to execute it.
Limited Power of Attorney: Administrative Representative Authorization
I, the undersigned ("Principal"), hereby grant to Neurvana AI, LLC d/b/a Remedy Support ("Agent") a Limited Power of Attorney for the sole and exclusive purpose of acting as my authorized administrative representative in connection with the specific insurance claim or billing matter identified during the Remedy Support intake process ("the Matter"). This grant of authority is strictly limited in scope as described below.
Scope of Authorized Actions
The Agent is authorized to: contact insurance carriers, third-party administrators, health plans, managed care organizations, and healthcare billing departments by telephone, fax, email, or written correspondence; identify itself as my authorized administrative representative; request claim status information, denial rationale, and appeals process information; submit administrative appeal correspondence and supporting documentation; request and receive claim-related information and correspondence directed to me in connection with the Matter; follow up on submitted appeals and administrative requests.
Limits of Authorized Actions
This Limited Power of Attorney does not authorize the Agent to: settle, compromise, or resolve the Matter without my express approval; accept or receive insurance proceeds, payments, or reimbursements on my behalf; endorse checks or negotiate any financial instrument; execute any release, waiver, or agreement that binds me legally; waive any legal right on my behalf; initiate litigation, arbitration, or any legal proceeding; make any healthcare or treatment decision; act beyond the scope of the identified Matter; or delegate this authority to any party outside of Neurvana AI, LLC and its authorized personnel and contractors.
Duration
This Limited Power of Attorney shall remain in effect until the earliest of: final administrative closure of the Matter as determined by Remedy Support; written revocation by the Principal delivered to compliance@remedy.support; or three (3) years from the date of execution.
Right to Revoke
I understand that I may revoke this Limited Power of Attorney at any time by delivering written notice to compliance@remedy.support. Revocation is effective upon receipt and does not affect actions already taken in good-faith reliance on this authorization. Revocation will result in termination of Services.
Acknowledgment
By signing below, I confirm that I am the patient identified in this intake submission, or I am legally authorized to act on behalf of that patient; I have read and understand the scope and limits of the authority granted herein; I am voluntarily granting this authority; and I understand that this is a legal instrument that Remedy Support will rely upon when acting on my behalf.
Electronic Execution
This Limited Power of Attorney is executed electronically through the Remedy Support intake platform. The electronic signature captured below, together with the associated timestamp and session record, constitutes a legally valid and binding execution of this instrument under the E-SIGN Act and the New York Electronic Signatures and Records Act (ESRA).
Version 1.0 · Effective June 1, 2026 · Incorporated into and subject to the Remedy Support Terms of Service.
Your signature legally executes this Limited Power of Attorney. By adopting it, you authorize Remedy Support, acting as your limited representative, to apply it to documents and correspondence reasonably necessary to administer and submit your insurance appeal. Your signature is encrypted, stored securely, and used only within the scope of this authorization.
Supporting Documents
Your documents are how we make the case. The stronger your evidence, the stronger your appeal.
Denial letter or explanation of benefits
RequiredThis tells us exactly why your claim was denied. We cannot draft your appeal without it.
Click to upload or drag and drop here
PDF, JPG, PNG, HEIC · up to 10 MB each · shares an 8-file total with supporting documents below
Don't have it yet?
- Log into your carrier's member portal and look under "Claims" or "EOB."
- Call the member services number on the back of your insurance card and ask for your EOB. Carriers are required to provide it.
Additional supporting documents
OptionalUpload anything else that strengthens your case. Common examples:
- Itemized medical bills or facility statements
- Prior authorization records
- Letters from your treating provider
- Correspondence with your carrier
Click to select files or drag and drop here
PDF, JPG, PNG, HEIC · up to 10 MB each · max 8 files total, shared with the denial letter/EOB upload above
Review and Submit
Take a moment to confirm your claim details are correct. Once submitted, your appeal enters our queue immediately.
Case Summary
$49
No hidden fees. No subscription. No percentage of your successful claim.
Payment is processed securely through Stripe. Your encrypted personal information is never passed to Stripe or any payment processor. By submitting, you agree to our Refund and Cancellation Policy.
Filing an appeal does not guarantee a change in your carrier's determination. We guarantee the quality and timely transmission of your administrative appeal, not its outcome.
This denial isn't a fit for our service yet.
Based on the denial reason you selected, winning this dispute comes down to clinical or benefit-design judgment. The administrative appeal we build is not designed to argue that kind of case. Filing a weak appeal can burn one of your limited appeal levels, so we won't take your payment for a case we can't argue well.
You have not been charged, and no case has been created.
What you can do
Double-check your denial letter. Denial reasons are often miscategorized. If your letter actually cites a missing prior authorization, a referral issue, late filing, or a surprise bill for emergency care, go back and select that reason instead.
Get free help with this type of denial. Every state has a Consumer Assistance Program or Department of Insurance that helps people appeal clinical denials at no cost. Your treating provider's office can also often appeal on your behalf.
Questions about this decision? Contact support.
Your appeal is in.
What happens next
Your claim details have been received and your case has entered our queue. Your appeal is being drafted from your anonymized claim data. A licensed advocate will review it for accuracy and completeness before anything leaves our system. Once approved, your appeal will be faxed directly to your carrier. You will receive an email confirmation the moment it is transmitted.
You do not need to call your insurance company. You do not need to follow up with us. We will contact you when your appeal has been sent.
You will need your case reference number and the mobile number you provided during intake to access your case.
A note on timing
Appeal drafting and advocate review typically complete within one to two business days. Transmission to your carrier follows immediately after sign-off. Carrier response times vary and are outside our control, but we will keep your case status updated throughout.
Filing an appeal does not guarantee a change in your carrier's determination. We guarantee the quality and timely transmission of your administrative appeal, not its outcome.