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How to fill out the Claim Reconsideration - Commongroundhealthcareorg online
Completing the Claim Reconsideration form for Common Ground Healthcare is an essential step in addressing any disputes regarding claims. This guide provides clear and supportive instructions for filling out the form accurately and effectively.
Follow the steps to complete the Claim Reconsideration form online.
- Press the ‘Get Form’ button to access the Claim Reconsideration form and open it in the editor.
- Fill in the contact information section. Provide your contact name, company, telephone, and email as these details will facilitate communication with the claims department.
- In the 'RE' section, indicate the relevant details about your claim. Ensure you provide accurate and complete information to avoid any delays.
- Complete the patient information section by entering the patient's name, CGHC member ID number, date of birth, date of service, charged amount, and claim number, if available.
- Specify the provider's information, including the provider's name and Tax Identification Number (TIN). This is critical to ensure the correct provider is referenced.
- Choose the subject of your reconsideration by marking the appropriate checkbox: payment, benefit, or medical necessity.
- In the narrative section, describe the reason for your request for reconsideration. Be concise but provide enough context to support your claim.
- Provide details for each service including the date of service, CPT code, charged amount, any modifiers, and the expected reimbursement.
- If you have multiple claims related to your request, attach a spreadsheet with the required columns as labeled in the form and include the claim numbers where possible.
- Once all sections are completed, save your changes. You can then download, print, or share the form as needed.
Don't delay in submitting your request; complete your Claim Reconsideration form online today.
Appeals are typically reviewed by a separate entity, such as an independent review organization (IRO), that is unbiased and impartial. Reconsiderations, on the other hand, are usually reviewed by the same payer that initially denied the claim.
Fill Claim Reconsideration - Commongroundhealthcareorg
This form is not intended for: • Submission of corrected claims. • Appeals of medical necessity decisions obtained through the prior authorization process. To: Common Ground Healthcare Cooperative. ATTN: Claims Department. The preferred method of submission for appeals is through the Common Ground Healthcare. Cooperative (CGHC) provider portal. View complaints of Common Ground Healthcare Cooperative filed with BBB. BBB helps resolve disputes with the services or products a business provides. This Form A relates to the Proposed Affiliation of Common Ground Healthcare.
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