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                Get Connecticare Resubmission Request Form
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How to fill out the Connecticare Resubmission Request Form online
The Connecticare Resubmission Request Form is a key document for users submitting a claim adjustment or corrected claim. This guide will provide clear and detailed instructions for successfully completing the form online.
Follow the steps to accurately complete the form online.
- Press the ‘Get Form’ button to access the Connecticare Resubmission Request Form and open it in your document management system.
- Begin by entering the 'Date Requested' in the designated field. Make sure to include the date when you are submitting the request.
- Fill in the 'Claim #' field with the relevant claim number associated with your request.
- If applicable, enter the 'NDC# or formula HCPC' in the specified section to identify any related pharmaceutical or procedural codes.
- Provide the 'Date of Service,' indicating when the relevant medical service was performed.
- Include the 'Provider Name,' which refers to the healthcare provider associated with the claim.
- In the 'Member Name' section, enter the name of the member for whom the claim is being submitted.
- Fill out the 'Contact Name' field with the name of the person submitting the request.
- Input the 'Member ID #' to ensure that the request is linked to the appropriate user account.
- Enter the 'Contact Phone' number where you can be reached for any follow-up questions.
- Indicate whether you received any payment for the claim by selecting the appropriate 'Yes' or 'No' box.
- If you selected 'Yes,' check only one box below to describe the reason for your request, and attach a corrected CMS 1500/UB04 as applicable.
- If you selected 'No,' check one box that best describes your reason for submission and ensure a corrected CMS 1500/UB04 is attached.
- Finally, send the completed form to ConnectiCare at the address provided: Attn: Claims - Resubmission Request, P.O. Box 4000, Farmington, CT 06034-4000. You can also reach out to Provider Services at 1-877-224-8230 for any inquiries.
- Once you have filled out all required fields accurately, you can save your changes, download the form, print it, or share it as necessary.
Complete your Connecticare Resubmission Request Form online today to ensure prompt processing.
To fill out a reimbursement claim form, it is essential to collect all relevant documentation beforehand. Using the Connecticare Resubmission Request Form can simplify this process. Provide a detailed account of each expense, including dates and descriptions. After completing the form, carefully review it for accuracy and completeness before submitting it for processing.
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