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Get Request For Claim Review Form - Fallon Community Health Plan
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How to fill out the Request For Claim Review Form - Fallon Community Health Plan online
This guide provides step-by-step instructions on filling out the Request For Claim Review Form for Fallon Community Health Plan. By following these guidelines, users can ensure a smooth submission process for their claim review requests.
Follow the steps to successfully complete the form
- Click ‘Get Form’ button to obtain the Request For Claim Review Form and open it in your preferred editor.
- Begin by entering the date of the request in the 'Today’s Date' field (MM/DD/YY). Ensure all required fields marked with an asterisk (*) are completed.
- Next, proceed to the Member / Claim Information section. Provide the necessary details including Member ID, Member Name, Date(s) of Service (MM/DD/YY), Claim Number, and Denial Code.
- Before concluding, ensure you attach all necessary supporting documentation to the completed Request For Claim Review Form, as required for your specific review type.
Complete your documents online to facilitate a timely and effective claim review process.
Fallon commercial HMO and Fallon Senior Plan™ HMO members require referrals from their PCP to receive care from a specialist. POS (FlexCare Select) members have the option of receiving out-of-network care without a referral. PPO members do not need a referral for specialty services.
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