Get Fidelis Section Thirteen Forms

Filling out the Fidelis Section Thirteen Forms online is an essential process for providers seeking administrative review of previously processed claims. This guide will provide clear, step-by-step instructions to help you navigate the form efficiently and effectively.

Follow the steps to complete the Fidelis Section Thirteen Forms online

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the member’s name and member ID in the designated fields. Ensure accuracy to prevent delays in processing.
3. Next, input the claim number along with the date of service (DOS) in the respective fields.
4. Fill in the provider's name and either the national provider identifier or tax identification number.
5. Enter the name of the requestor and the date of the request. Ensure this matches the individual who is handling the appeal.
6. Select the reason for your request from the provided options. For specific choices, such as 'Claim/service denied for timely filing,' attach the relevant documentation as required.
7. For any other reasons, provide a detailed explanation in the space provided, ensuring you include all necessary information.
8. Review your entries carefully to ensure all sections are completed and accurate.
9. Once finished, you can save changes, download, print, or share the completed form as needed.

Complete your forms online now to ensure timely processing of your claims.