There may be times when you disagree with how we’ve processed a claim for one of your patients. Perhaps you disagree with:

• How we applied coding and payment rules
• Our interpretation of the terms of the member’s benefit plan, such as the definition of medical necessity
• Our decision regarding provider versus member financial responsibilities

We encourage you to contact Provider Services any time you have questions about how a claim was processed. In some cases, we may be able to resolve the issue simply by clarifying how the decision was made. There may be instances, however, when you want to formally request a provider reconsideration to investigate the outcome of a finalized claim.

Submitting a Reconsideration Request

Please submit reconsideration requests in writing. Your request should include:

• Provider Reconsideration Form, completed in its entirety
• An explanation of the issue(s) you’d like us to reconsider
• Any supporting documentation, such as:
  • The patient’s health history
  • Operative reports, office notes, pathology reports, hospital progress notes, radiology reports and/or lab reports

Send the form and supporting materials to the appropriate fax number or address noted on the form.