Get Provider Dispute Claim Reconsideration Request Form - Ccai

Filling out the Provider Dispute Claim Reconsideration Request Form - CCAI online is an essential process for healthcare professionals seeking to appeal a claim decision. This guide provides clear, step-by-step instructions to ensure your submission is complete and accurate.

Follow the steps to complete your request form effectively.

1. Press the ‘Get Form’ button to access the Provider Dispute Claim Reconsideration Request Form - CCAI and open it in your document editor.
2. Enter today's date at the top of the form.
3. In the Member Information section, carefully fill in the member's last name, first name, date of birth, and Member Identification Number (EIN).
4. Move to the Physician/Health Care Professional Information section. Fill in the contact name, phone number (with area code), and email address.
5. Provide the healthcare professional name as listed on the Evidence of Payment (EOP) and enter the Tax Identification Number (TIN).
6. Complete the Facility/Group Name section with relevant details, followed by the name (last and first) and contact address including street address, city, state, and zip code.
7. In the Reason for Request section, specify the date of service, claim number, total charges, and expected amount owed.
8. Select the appropriate reason for the request from the provided options, detailing any comments or reasons for the appeal in the comments section.
9. Attach any required additional documentation such as a copy of the initial claim, a copy of the EOP, and any other supporting documents.
10. Once all fields are completed and documents are attached, save your changes. You can download, print, or share the completed form as needed.

Start the process now by completing your Provider Dispute Claim Reconsideration Request Form online.