Form Pro5 - Claim Reconsideation Request - 1199seiu Benefit Funds - 2013

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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

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