Get Request For Reconsideration Form - Qual Choice

Filling out the Request for Reconsideration Form for Qual Choice can help you address denied claims efficiently. This guide will walk you through each section and field of the form to ensure you submit a complete and accurate request.

Follow the steps to fill out the form accurately.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. In Section I: General Information, enter today's date in MM/DD/YYYY format. Select one of the options: Practitioner, Hospital, or Other Healthcare Provider. Provide the provider's name and their QualChoice ID number, as well as the date of service as indicated on the explanation of benefits (EOB) or remittance advice (RA). Fill in the name of the person requesting the reconsideration, along with their phone number, fax number, QualChoice ID number, claim number from the EOB or RA, email address, and the patient's name.
3. In Section II: Reconsideration Information, indicate the reason for reconsideration by checking the appropriate box. If necessary, provide additional comments or documentation as specified for each option, ensuring you include details for circumstances like duplicate payment received or medical necessity.
4. In Section III: Required Attachments Checklist, make sure to include the Provider Remittance Advice (RA) or explanation of benefits (EOB), along with the claim form without any markings or highlights. Attach any other required documentation specified under the selected reconsideration reason.
5. Once the form is fully completed and all required documentation is gathered, you can save your changes. After saving, consider downloading the form for record-keeping. Finally, print a copy or share it as needed before submission.

Take the next step and complete your Request for Reconsideration Form online today.