1199SEIU Benefit Funds
Medical Claims Reconsideration, PO Box 717, New York, NY 10108-0717
Tel (646) 473-7160 • Fax (646) 473-7088 • Outside NYC area codes: (800) 575-7771 •
CLAIM RECONSIDERATION REQUEST
COMPLETE A SEPARATE FORM FOR EACH CLAIM • PLEASE PRINT CLEARLY IN BLUE OR BLACK INK
Date: _______________________________________
Patient name: _______________________________________________________
Health ID #: __________________________________
❑
❑
Claim number: _______________________________________________________
Original claim:
Paper
Electronic
Diagnosis code: ____________________________________________________________________________________________________
Rendering provider name: ____________________________________________________________________________________________
Facility/Group name: ________________________________________________________________________________________________
Provider Tax ID #: ________________________________________ Provider NPI #: _____________________________________________
Amount billed: ___________________________________________ Amount paid: ______________________________________________
Date(s) of service: ________________________________________ Date paid: ________________________________________________
REASON FOR RECONSIDERATION: Indicate the reason(s) why you are filing this request (check all that apply):
❑
1. Claim was previously denied as “Exceeds Timely Filing” (Attach proof of timely filing)
❑
2. Claim was previously denied with request for clarification/additional information (Attach requested documents)
❑
3. Claim was previously denied due to a lack of information regarding “Coordination of Benefits” information
(Attach primary carrier’s EOB)
❑
4. Claim was previously denied due to submission of incorrect information (Explain correction below)
❑
5. Claim was previously denied due to a dispute of the applied contracted rate (Explain below)
❑
6. Claim was previously denied with request for revisions that follow Correct Coding Initiative (CCI) guidelines for
bundled claims (Attach revised coding and explain below)
❑
7. Claim was previously denied for lack of authorization/medical necessity
(Attach proof of authorization/clinical documentation)
❑
8. Claim was previously denied because an incorrect Tax Identification Number (TIN) was provided
❑
9. Claim was previously denied because member was deemed ineligible for services provided, but member is eligible
❑
10. Other (Explain here): ________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Reconsideration request must be submitted
within 180 days of the date the claim was originally denied or paid.
PR05 • 7/13