Provider Reconsideration Form Instructions
This file provides detailed instructions on how healthcare providers can submit reconsideration requests regarding claim payments. It includes essential guidelines, necessary fields, and contact information required for submission. Use this form to address payment disputes and provide supporting documentation.
Edit, Download, and Sign the Provider Reconsideration Form Instructions
Form
eSign
Add Annotation
Share Form
How do I fill this out?
To fill out this form, you'll need to provide essential information regarding the claim you are disputing. Ensure that all necessary fields are completed accurately to prevent any delays in processing. Gather supporting documentation to accompany your reconsideration request.
How to fill out the Provider Reconsideration Form Instructions?
1
Enter the Member ID Number including the prefix.
2
Write the Date of Request.
3
Fill in the Provider/NPI Number and Member Name.
4
Enter the Service Date and Claim/Reference Number.
5
Add any Notes or Comments and submit the form via fax or mail.
Who needs the Provider Reconsideration Form Instructions?
1
Healthcare providers needing to dispute a claim payment.
2
Providers submitting reconsideration requests for payment discrepancies.
3
Providers in Tennessee or contiguous counties handling Commercial and BlueCare patients.
4
Out-of-state healthcare providers when instructed by BlueCross to use this form.
5
Healthcare professionals addressing non-compliance denial disputes.
How PrintFriendly Works
At PrintFriendly.com, you can edit, sign, share, and download the Provider Reconsideration Form Instructions along with hundreds of thousands of other documents. Our platform helps you seamlessly edit PDFs and other documents online. You can edit our large library of pre-existing files and upload your own documents. Managing PDFs has never been easier.
Edit your Provider Reconsideration Form Instructions online.
PrintFriendly allows you to easily edit this PDF form using our integrated PDF editor. Add or modify text within the document and highlight necessary sections for clarity. Ensure all required fields are accurately filled before finalizing your form.
Add your legally-binding signature.
With PrintFriendly's new feature, you can sign the PDF directly within the platform. Upload your digital signature or draw it directly on the document using our tools. Securely apply your signature to complete and validate the form.
Share your form instantly.
Share your completed PDF file conveniently with PrintFriendly's sharing feature. Send the document via email to relevant recipients or generate a shareable link. Export and save your finalized form to share across various platforms.
How do I edit the Provider Reconsideration Form Instructions online?
PrintFriendly allows you to easily edit this PDF form using our integrated PDF editor. Add or modify text within the document and highlight necessary sections for clarity. Ensure all required fields are accurately filled before finalizing your form.
1
Open the Provider Reconsideration Form on PrintFriendly.
2
Click the edit button to enable PDF editing mode.
3
Fill in the necessary fields with the required information.
4
Attach any required supporting documents.
5
Save and download the completed form to submit it.
What are the instructions for submitting this form?
To submit the Provider Reconsideration Form, fax your completed form and any supporting documentation to (423) 535-1959. Alternatively, mail your request to BlueCross BlueShield of Tennessee, 1 Cameron Hill Circle, Suite 0039, Chattanooga, TN 37402-0039. Ensure that all necessary details and supporting documents are included to prevent delays.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates for this form in 2024 and 2025.
What is the purpose of this form?
The primary purpose of the Provider Reconsideration Form is to allow healthcare providers to request a reconsideration of a claim payment decision. The form helps providers address any discrepancies or disputes related to claim payments by submitting necessary documentation and information. By processing these reconsideration requests, BlueCross BlueShield of Tennessee ensures fair and accurate claim handling.
Tell me about this form and its components and fields line-by-line.
- 1. Member ID Number: Enter the Member’s ID number including the prefix.
- 2. Date of Request: Fill in the date when the reconsideration request is being made.
- 3. Provider/NPI Number: Provide the healthcare provider’s NPI number.
- 4. Member Name: Enter the name of the member associated with the claim.
- 5. Provider Name: Write the name of the provider submitting the form.
- 6. Provider Contact Name: Include the name of the contact person for the provider.
- 7. Service Date for Reconsideration: Enter the date of service for which reconsideration is being requested.
- 8. Claim/Reference Number: Provide the claim or reference number associated with the service.
- 9. Provider Phone Number: Include the phone number of the provider.
- 10. Provider Fax Number: Enter the fax number of the provider.
- 11. Notes Comments: Add any relevant notes or comments related to the reconsideration request.
What happens if I fail to submit this form?
Failure to submit this form can result in the inability to address claim payment disputes. This can further lead to unresolved payment issues and potential delays in reimbursement.
- Unresolved Payment Disputes: Without submitting the form, payment discrepancies may remain unresolved.
- Delayed Reimbursement: Failure to submit the form can result in delays in receiving reimbursements.
How do I know when to use this form?
- 1. Dispute a Claim Payment: When you need to request a review or reconsideration of a claim payment decision.
- 2. Supporting Documentation: Include necessary documents and information related to the reconsideration request.
- 3. Corrective Measures: Address and rectify any discrepancies related to claim payments.
Frequently Asked Question
How do I fill out the Provider Reconsideration Form?
You can fill out the form by entering the necessary claim information, including Member ID, Date of Request, Provider/NPI Number, and other required fields.
Can I edit the form on PrintFriendly?
Yes, PrintFriendly allows you to edit the form using our integrated PDF editor. You can add text, highlight sections, and upload supporting documents.
Can I sign the PDF form on PrintFriendly?
Absolutely! You can upload or draw your digital signature directly on the form using PrintFriendly's signing feature.
How do I share the completed form?
You can share the completed form via email, generate a shareable link, or export and save the form to share across other platforms.
What information is required for the reconsideration form?
The form requires information such as Member ID Number, Provider/NPI Number, Claim/Reference Number, and any supporting documentation.
Can I attach supporting documents to the form?
Yes, you can attach supporting documents by uploading them directly to the PDF form using PrintFriendly's editor.
Where do I send the completed reconsideration form?
Fax the completed form to (423) 535-1959 or mail it to BlueCross BlueShield of Tennessee at their specified address.
Can this form be used for non-compliance denials?
No, the Provider Appeal Form should be used for submitting non-compliance related denials instead of this Reconsideration Form.
Is there a limit to the number of reconsiderations I can submit?
Yes, only one reconsideration is allowed per claim for the same or similar issue.
Can I submit appeals requests using this form?
No, appeals requests cannot be submitted using this Reconsideration Form.
Related Documents - Reconsideration Form
Provider Request for Reconsideration and Claim Dispute
This form is essential for providers wishing to appeal a claim decision. It guides the submission of reconsideration requests and disputes. Complete it accurately to ensure efficient processing of your requests.
Molina Healthcare Claim Reconsideration Request Form
This form is used for submitting claim reconsideration requests to Molina Healthcare. Please fill out the form with all required information and attach supporting documents. Incomplete forms will be returned to the submitter.
Wellcare Reconsideration Request Form Guidelines
This document provides essential information about the Wellcare Reconsideration Request Form. Users can follow the outlined guidelines to correctly complete and submit their requests. Ensure all necessary documentation is included for prompt processing.
Cigna Online Claim Reconsideration Overview and Instructions
This document provides a comprehensive overview of the online claim reconsideration feature on the Cigna for Health Care Professionals website. It outlines the key features, steps to initiate a claim search, and how to request a review for possible adjustments. Users will find this guide useful for navigating the claim reconsideration process efficiently.
United Healthcare Single Claim Reconsideration Form
This form is used by healthcare professionals to request reconsideration or correction of a previously submitted claim. It is necessary to submit a separate form for each claim. New claims should not be submitted with this form.
Molina Healthcare Medicare Claims Reconsideration Form
This form is used to request a reconsideration of claims processed by Molina Healthcare for Medicare services. It is essential for ensuring that your claims are properly addressed and resolved. Fill it out completely and submit it to initiate the reconsideration process.
Hospital Claim Reconsideration Request Form
This form is used to request a reconsideration of a hospital claim that has been denied or underpaid. It requires specific details about the claim, including identification and supporting documentation. Ensure to submit this form within 180 days of the claim's determination.
Appeal Request Form for Claim Reconsideration
The Appeal Request Form is used by providers for requesting a reconsideration of previously adjudicated claims. It facilitates the submission of necessary details such as billing provider information and claims information. This form ensures that providers can effectively communicate any issues or reasons for appeal regarding their claims.
