Get Bill Reconsideration Form

Filling out the Bill Reconsideration Form online is a straightforward process designed to help you request reconsideration from the client regarding billing issues. This guide will provide you with step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete the form online.

1. Click the ‘Get Form’ button to obtain the Bill Reconsideration Form and open it in your browser.
2. Enter the request date in the designated field to indicate when you are submitting your reconsideration request.
3. Select the appropriate network from the dropdown list, which includes options such as Aetna Signature Administrators, Aetna Workers’ Compensation Access, and Cofinity Auto Network.
4. Input the provider's name and service location, including street address, suite number, city, state, and ZIP code.
5. Enter the patient account number, along with the tax identification number and the PIN, in their respective fields.
6. Fill in the contact name, phone number, and email address for the provider or representative handling the request.
7. Provide the employee’s name and their address details, including street, apartment number if applicable, city, state, and ZIP code.
8. Input the employee's social security number or alternate member ID, as well as the date of birth.
9. Include the employer's name and the client's name to whom the bill relates.
10. Enter the date of service and the client bill ID or claim number for accurate tracking.
11. Specify the charge amount and the requested payment amount in the designated fields.
12. Provide a detailed statement outlining the reasons for reconsideration in the available text box.
13. Indicate whether you are attaching any additional documents by selecting 'Yes' or 'No' and, if applicable, provide a description of the documents.
14. Once you have completed all sections of the form, ensure all information is correct before saving your changes.
15. You can then download, print, or share the completed Bill Reconsideration Form as needed.

Start filling out your Bill Reconsideration Form online today to ensure timely processing of your request.