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You can submit claim reconsideration requests online.


We see you searched for “Claim Reconsideration Form.” Did you know you can use the claimsLink app to submit reconsideration requests? With the app, there’s no form to fax or mail, less paper to manage and your request will reach us faster.

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LAST MODIFIED 08.20.2018

To request reconsideration of a claim, please complete and mail this form along with a copy of the related provider remittance advice or explanation of benefits to the following address. Please submit a separate form for each claim reconsideration...

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LAST MODIFIED 12.26.2018

To request reconsideration of a claim, please complete and mail this form along with a copy of the related provider remittance advice or explanation of benefits to the following address. Please submit a separate form for each claim reconsideration...

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LAST MODIFIED 04.30.2018

This form is to be completed by physicians, hospitals or other health care professionals for paper Claim Reconsideration Requests for our members.

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LAST MODIFIED 01.03.2019

This form is to be completed by physicians, hospitals or other health care professionals to request a claim reconsideration for members enrolled in a benefit plans administered by UnitedHealthcare Community Plan of Michigan.

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LAST MODIFIED 07.01.2018

To request reconsideration, providers have 180 days from the date a claim denied in whole, partially or recoupment date of a claim or the MCO failed to issue a RA within 60 calendar days.

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LAST MODIFIED 06.27.2018

If you receive a clinical claim denial, you can submit a reconsideration request for a full medical necessity review. This reference guide explains the submission process of a claim reconsideration request form, as well as the information required.

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LAST MODIFIED 11.05.2018

Use this paper fax form to submit requests for the following states: Arizona, Hawaii, Iowa, Louisiana, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, Washington

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LAST MODIFIED 07.10.2018

Requests must be received within 180 days from the date of service (or per the terms of your contract). Please allow 45 business days to process this reconsideration request. Please return this completed form and any supporting documentation to ...

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LAST MODIFIED 06.19.2018

You can submit a reconsideration request for a full medical necessity review if you receive a clinical claim denial. This reference guide explains the submission process as well as the information required.

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LAST MODIFIED 11.20.2018

Forms and other resources for Virginia care providers.

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LAST MODIFIED 12.21.2018

Forms and other resources for New Mexico care providers.

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LAST MODIFIED 05.04.2018

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Hawaii Community Plan care providers.

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LAST MODIFIED 05.03.2018

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Iowa Community Plan care providers.

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LAST MODIFIED 05.03.2018

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Maryland Community Plan care providers.

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LAST MODIFIED 05.03.2018

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Nebraska Community Plan care providers.

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LAST MODIFIED 09.10.2018

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of New Jersey Community Plan care providers.

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