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  • Sanford Claim Reconsideration Form

Get Sanford Claim Reconsideration Form

CLAIM RECONSIDERATION REQUEST FORM Claim Number s Phone Number Contact Name Provider Facility Member Name Member ID Number Date of Service Date of Submission Reason you are requesting review for this claim Check one Corrected Claims Subrogation/Workers Compensation/Motor Vehicle Accident/Third Party Coordination of Benefits Initial Credentialing OB/GYN Package Billing/Antepartum Care Received incorrect insurance information on date of service Res.

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For a Standard Appeal: Sanford Health Plan, Appeals PO Box 91110 Sioux Falls, SD 57109-1110 Phone: (877) 652-8544 If you ask for a standard appeal by phone, we will send you a letter confirming what you told us.

If the member or the Non-Participating Practitioner and/or Provider, does not file the claim within one-hundred-eighty (180) days after the date that the cost was incurred, the member will be responsible for payment of the claim.

You have 1 year from the date of occurrence to file an appeal with the NHP. You will receive a decision in writing within 60 calendar days from the date we receive your appeal.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232