Get Claim Inquiry/adjustment Request Form - Coventry Health Care Of ...

Filling out the Claim Inquiry/Adjustment Request Form requires careful attention to detail to ensure that your request is processed effectively. This guide will provide you with step-by-step instructions on how to complete the form online, highlighting important sections and necessary information.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the Claim Inquiry/Adjustment Request Form and open it for editing.
2. In the Member Information section, fill in the member's name, ID number, and date of service. This information is vital for identifying the claim.
3. Provide the member's date of birth and claim number in the Claim Data section to further assist in processing your request.
4. In the Provider Data section, enter the provider's name, contact person, phone number, mailing address, fax number, and email address.
5. Select the specific request for review by marking the appropriate option, such as modifier/code review or timely filing. Include any necessary documentation as indicated.
6. In the description of request field, briefly explain the reason for your inquiry or adjustment request.
7. Review all entered information for accuracy, as incomplete forms will be returned without review.
8. Once all sections are completed, you can save your changes, download the form, print it, or share it as needed.

Start filling out your Claim Inquiry/Adjustment Request Form online today for quicker processing.