Get Scott And White Redetermination Form

Filling out the Scott And White Redetermination Form is an essential step in submitting a claim for adjustments or redetermination requests. This guide will walk you through the necessary steps to ensure your form is completed accurately and efficiently.

Follow the steps to effectively complete the form online.

1. Press the ‘Get Form’ button to access the Scott And White Redetermination Form. This will allow you to obtain the document needed to proceed with your request.
2. Begin filling out the form by entering the review submission date. This is the date you are submitting your redetermination request.
3. Input your contact name. This should be the name of the person submitting the redetermination request.
4. Provide your provider name. Ensure it matches the name associated with your medical practice or organization.
5. Enter your contact phone number. This number should be a reliable way to reach you regarding the request.
6. Fill in your provider NPI number. This unique identifier is crucial for processing your request.
7. Add the member's name. Include the name of the individual associated with the claim being reviewed.
8. Enter the provider address. This should be the official address of your practice or organization.
9. Input the SWHP member ID number. This is necessary for identifying the specific member associated with the claim.
10. Provide the SWHP claim number. This allows for easy tracking and identification of your claim request.
11. Fill in the date of service for the claim in question. This is the date when the medical service was rendered.
12. Choose the reason for redetermination that best represents your request. Options include filing limit, claim check/code editing, contracted rate or payment policy, COB, data entry error, or overpayment/underpayment (specify) among others.
13. Attach any pertinent supporting documentation that can assist in your claim, such as surgical notes, office visit notes, pathology reports, or medical records.
14. Once you have completed the form and attached any necessary documents, follow the mailing instructions carefully. Send the completed form to: Scott and White Health Plan, P.O. Box 21800, Eagan, MN 55121-0800. Ensure the request is submitted within the specified timeframe to avoid delays.

Complete your documents online today to ensure your redetermination request is processed smoothly.