Manual Reversal Request Form Instructions: Before completing this Manual Reversal Request Form, please try to reverse the claim electronically using the online system. If the reversal is rejected,.
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How to fill out the Manual Reversal Request Form - Abarca Health online
Filling out the Manual Reversal Request Form - Abarca Health is an essential step when electronic claim reversals are unsuccessful. This guide provides a clear, step-by-step approach to ensure you complete the form accurately and submit it correctly.
Follow the steps to complete the Manual Reversal Request Form.
- Click the ‘Get Form’ button to access the Manual Reversal Request Form and open it in the appropriate editor.
- In the 'Beneficiary Information' section, provide the name of the person and their cardholder ID.
- Next, move to the 'Pharmacy Information' section. Fill in the name of the pharmacy, NCPDP or NPI number, telephone number, fax number, contact person's name, and the current date.
- Proceed to 'Information on Claim #1'. Here, enter the date of service, prescription number, name of the medication, fill number being reversed, and the ICN (Approval Number).
- If you have additional claims, repeat step 4 for 'Information on Claim #2' and 'Information on Claim #3'. Make sure to fill in each corresponding field.
- In the 'Reason for reversal' section, provide a clear explanation regarding the need for the reversal. Be detailed for better clarification.
- At the bottom of the form, ensure the name of the authorized person is printed clearly, followed by their handwritten signature.
- Finally, after reviewing the form for completeness, fax it to (787) 777-1372. Ensure that this is the only fax number used for submission as any other will not process your request.
Complete your Manual Reversal Request Form online today to streamline your claims process.
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