Get 1199 Reconsideration Form

Filling out the 1199 Reconsideration Form online can streamline the process of disputing a medical claim denial. This guide provides step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to fill out the 1199 Reconsideration Form online.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editable format.
2. Enter the date on which you are filing the reconsideration request at the top of the form.
3. Provide the patient’s name clearly in the designated field.
4. Input the health ID number associated with the patient’s account.
5. Fill in the claim number for which you are requesting reconsideration.
6. Indicate whether the original claim was filed as a paper claim or an electronic claim by checking the appropriate box.
7. Enter the diagnosis code relevant to the claim.
8. Write the name of the rendering provider for the services received.
9. Fill in the facility or group name where the services were provided.
10. Provide the provider’s Tax Identification Number (TIN) and National Provider Identifier (NPI).
11. Input the total amount billed and the amount that was paid.
12. List the date(s) of service and the date the claim was paid.
13. In the reason for reconsideration section, check all applicable boxes to indicate the reasons for your request, providing any necessary documentation as instructed.
14. If necessary, provide explanations for corrections or additional details in the designated areas.
15. Review all entered information for accuracy and clarity.
16. Once completed, you can save your changes, download, print, or share the completed form as needed.

Complete your documents online to ensure a smooth filing process.