Get Health Claim Resubmission Request Form - Wea Trust

This guide provides clear and supportive instructions on how to complete the Health Claim Resubmission Request Form for WEA Trust online. Follow these steps to ensure your form is filled out accurately and submitted correctly.

Follow the steps to properly complete your form.

1. Press the ‘Get Form’ button to access the Health Claim Resubmission Request Form and open it for editing.
2. Fill in the 'Date requested' field with the current date.
3. Enter the 'Tax ID#' of the provider for the claim.
4. Provide the 'Claim #' associated with the original claim.
5. Input the 'NPI#' (National Provider Identifier) as applicable.
6. Complete the 'Date of service' section with the date you provided the service.
7. Write the 'Provider name' who rendered the service.
8. Include the 'Member name' for whom the service was provided.
9. Fill in the 'Contact name' for questions regarding the claim.
10. Enter the 'Member ID#' assigned to the member.
11. Provide a 'Contact phone' number where you can be reached.
12. Specify the 'Billed Amount' for the services rendered.
13. Add your 'Contact Email' for any correspondence.
14. Indicate whether you received any payment for the claim by selecting 'Yes' or 'No'.
15. Check all applicable boxes to indicate the reason for your resubmission.
16. Attach a corrected CMS-1500/UB-04 form, if necessary.
17. Supply any necessary explanation in the space provided if applicable.
18. Review the completed form for accuracy before submission.
19. Once completed, you can save changes, download, print, or share the form as needed.

Complete your Health Claim Resubmission Request Form online today to ensure timely processing!