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Advanced Health 289 La Clair Coos Bay, OR 97420 Phone 5412697400 Fax 5412692052 Toll Free 8002640014 TTY: 8777697400How to Complete Provider Appeal Request All lines of the form must be completed
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How to fill out provider-reconsideration-request-form-auth-appeal

01
Fill in your personal information such as name, address, phone number, and date of birth.
02
Provide details about the claim that is being disputed, including the date of service, provider name, and reason for the appeal.
03
Attach any supporting documentation that may help to support your appeal, such as medical records or invoices.
04
Sign and date the form before submitting it to the appropriate department for review.

Who needs provider-reconsideration-request-form-auth-appeal?

01
Individuals who have had a claim denied by their insurance provider and wish to appeal the decision.
02
Healthcare providers who have had a claim denied and are seeking reconsideration from the insurance company.
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The provider-reconsideration-request-form-auth-appeal is a document used by healthcare providers to formally request a review of a decision made by an insurance company or other payer regarding authorization of services or claims.
Healthcare providers who have had a prior authorization request denied or a claim rejected are required to file the provider-reconsideration-request-form-auth-appeal.
To fill out the provider-reconsideration-request-form-auth-appeal, providers should include patient information, details of the service requested, the reason for the appeal, and any supporting documentation that justifies the request for reconsideration.
The purpose of the provider-reconsideration-request-form-auth-appeal is to allow providers to challenge and seek reevaluation of decisions made by payers regarding the approval of services or reimbursement for claims.
Information that must be reported includes the patient's name, insurance information, details of the service or procedure, the date of service, the reason for the appeal, and any relevant medical records or documentation.
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