Get Coventry Ne Reconsideration Form

Completing the Coventry Ne Reconsideration Form online can be a straightforward process when you have clear guidance. This document is designed to help users navigate through the necessary fields and ensure all required information is accurately submitted.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ to obtain the form and open it in the editor.
2. Fill out the 'From' section by providing your name and contact information. Ensure that all details are accurate to facilitate communication during the reconsideration process.
3. In the 'Mail To' section, enter the address: CoventryCares Attn: Reconsideration Team PO Box 7810 London, Kentucky 40742.
4. Select the relevant checkbox indicating the nature of your request, such as 'Corrected Claim', 'Proof of Timely Filing', or 'Request for Reconsideration'.
5. Input the Member Name and Member ID Number in the designated fields to identify the individual associated with the claim.
6. Provide the Date(s) of Service and the Remittance Advice Date. This information helps track the claim process and establish the timeline of services rendered.
7. Enter the Amount Billed and Amount Paid, detailing the financial aspects of the claim.
8. List the Claim Number(s) associated with your submission for easy reference.
9. Use the provided space to include any additional necessary information along with your attachment(s) for thorough reconsideration.
10. Finally, ensure that you sign and date the form at the bottom to validate your submission.
11. Once you have completed the form, save any changes, and consider downloading, printing, or sharing the form as needed.

Complete your Coventry Ne Reconsideration Form online today for a smoother reconsideration process.