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Get Virginia Premier Reconsideration Form
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How to fill out the Virginia Premier Reconsideration Form online
The Virginia Premier Reconsideration Form allows users to submit requests for reconsideration of claims. This guide provides a clear, step-by-step approach to help you complete the form online effectively.
Follow the steps to fill out the Virginia Premier Reconsideration Form
- Click the ‘Get Form’ button to obtain the form and open it in your preferred interface for editing.
- Begin filling in the provider information where indicated. This includes sections for the provider's name and NPI number, as well as their fax number, which will be necessary for follow-up communication.
- Input the insured's Medicaid ID number in the designated field, ensuring accuracy to avoid complications. This number is crucial for identifying the individual associated with the claim.
- Complete the 'Claim Filed On' section by selecting either 'CMS 1500' or 'UB 04'. This denotes the type of claim form submitted previously, helping to categorize your request appropriately.
- Provide the patient’s name and account number in the fields provided. This information is vital for tracking the status of the reconsideration request.
- Fill out the dates of service relevant to the claim, as this specifies the time frame of the healthcare services rendered.
- In the 'Reason for Request' section, select the applicable reason for your reconsideration. Options may include adjustment, special consideration, or other circumstances detailed.
- Explain the problem and the action you are requesting in the provided text box. Be as detailed and clear as possible to ensure your request is understood.
- After completing all fields, ensure that you review your entries for accuracy. Once confirmed, you can save your changes, download the form, print it, or share it as needed.
Start filling out your Virginia Premier Reconsideration Form online today!
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Virginia Premier was acquired by Sentara Healthcare, leading to a comprehensive integration of services. This acquisition is designed to provide members with enhanced health care options and improved service delivery. As part of this transition, resources such as the Virginia Premier Reconsideration Form will continue to be available, ensuring users have the necessary support as they navigate their health care journeys.
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