MO Coventry Health Care Request for Reconsideration Form 2012-2025 free printable template

Request for Reconsideration Form Mails to the Claims address on the back of the member ID card. Date: PATIENT INFORMATION: Product: Coventry Health Care of Missouri, Inc. Medicare CMR CHC/MOA SO Member

How to fill out MO Coventry Health Care Request for Reconsideration

How to fill out MO Coventry Health Care Request for Reconsideration Form

1. Obtain the MO Coventry Health Care Request for Reconsideration Form from the official website or contact customer service.
2. Fill out the patient's personal information including name, address, date of birth, and insurance policy number.
3. Provide details about the decision you are contesting, including the date of the decision and the reasons for reconsideration.
4. Attach any supporting documentation that provides evidence for your case, such as medical records or correspondence.
5. Sign and date the form confirming that all information is accurate and complete.
6. Submit the completed form and any attachments to the address specified on the form, either by mail or electronically if allowed.

Who needs MO Coventry Health Care Request for Reconsideration Form?

1. Patients who have received a denial of medical services or benefits from MO Coventry Health Care.
2. Healthcare providers acting on behalf of a patient seeking reconsideration of a claim decision.

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What is MO Coventry Health Care Request for Reconsideration Form?

The MO Coventry Health Care Request for Reconsideration Form is a document used by providers or members to formally request a review of a denied claim or decision made by Coventry Health Care.

Who is required to file MO Coventry Health Care Request for Reconsideration Form?

Any healthcare provider or member who disputes a claim denial by Coventry Health Care is required to file the MO Coventry Health Care Request for Reconsideration Form.

How to fill out MO Coventry Health Care Request for Reconsideration Form?

To fill out the form, you need to provide information such as the patient's details, claim number, reason for reconsideration, and any supporting documents that validate your request.

What is the purpose of MO Coventry Health Care Request for Reconsideration Form?

The purpose of the form is to allow providers or members to formally contest and seek a review of decisions made by Coventry Health Care regarding claim denials or other adverse decisions.

What information must be reported on MO Coventry Health Care Request for Reconsideration Form?

The information that must be reported includes the patient's name, member ID, provider information, claim number, date of service, reasons for the request, and any additional documentation supporting the appeal.