Get Coventry Reconsideration Form

This guide provides a clear and supportive overview of how to fill out the Coventry Reconsideration Form online for users seeking to address claim denials with CoventryCares of Kentucky Medicaid. By following these straightforward steps, individuals can ensure their submissions are complete and accurate.

Follow the steps to fill out the Coventry Reconsideration Form online

1. Press the ‘Get Form’ button to access the Coventry Reconsideration Form and open it in your preferred online editor.
2. Begin by entering the sender's details in the 'FROM' section, including the name, address, and contact information.
3. In the 'Member Name' field, specify the name of the member related to the claim in question.
4. Provide the corresponding 'Member ID Number' associated with the claim.
5. Fill in the 'Date(s) of Service' for which the reconsideration is being requested.
6. Enter the 'Remittance Advice Date' to indicate when the claim response was received.
7. State the 'Amount Billed' for the services rendered and the 'Amount Paid' as per the previous decision.
8. List the 'Claim Number(s)' related to the request for reconsideration.
9. In the designated section, outline any additional information that may assist in the reconsideration, clearly explaining your reasons and including any necessary attachments.
10. Finally, ensure you sign and date the form to authenticate your submission.

Complete the Coventry Reconsideration Form online to ensure your claim is reviewed promptly.