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Get Regence Provider Appeal Form 2020-2025
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How to fill out the Regence Provider Appeal Form online
Filling out the Regence Provider Appeal Form online is an essential process for providers who wish to contest a decision made by Regence. This guide will outline each step clearly, ensuring that you can complete the form accurately and efficiently.
Follow the steps to successfully complete the appeal form.
- Click ‘Get Form’ button to access the appeal form and open it in your editing interface.
- Begin by entering your contact information in the required fields marked with an asterisk (*). This includes your name, organization or provider name, email address, phone number, fax number, NPI Number, and Tax ID Number.
- Next, provide details about the claim you are appealing. Indicate whether this claim has been appealed to Regence before by selecting 'Yes' or 'No.' If 'Yes,' a copy of the appeal determination letter must be attached.
- Fill in the Regence Claim Number, the date(s) of service, member ID number, member name, and the member's date of birth.
- Enter the total billed amount for the services provided.
- If your appeal relates to the lack of pre-authorization or notification, select the reason that applies to your situation from the provided options.
- In the space provided, summarize your reasoning for the appeal. Describe in detail why you believe the denial should be overturned, ensuring that your evidence supports adherence to Regence policy.
- If your appeal concerns specific coding rules or medical necessity, provide a detailed explanation of your dispute and the desired outcome.
- Compile any necessary documentation that supports your appeal, such as chart notes or operative reports. Attach these documents to your form.
- Review your completed form for accuracy, then fax the entire document to 1 (866) 273-1820 to submit your appeal.
Complete your Regence Provider Appeal Form online to ensure your appeal is processed effectively.
Filing an appeal in Texas can be straightforward if you utilize the Regence Provider Appeal Form correctly. Make sure to document your reasons clearly and attach any relevant documents that substantiate your case. For additional assistance, consider using platforms like uslegalforms, which provide resources tailored to help you navigate the appeal process effectively.
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