Get Request For Reconsideration - Qualchoice

Filling out the Request For Reconsideration form is an essential step for healthcare providers seeking to have claims reviewed by QualChoice. This guide provides a clear, step-by-step approach to ensure that your request is submitted correctly and efficiently.

Follow the steps to complete the Request For Reconsideration form online.

1. Press the ‘Get Form’ button to obtain the Request For Reconsideration form and open it in your preferred electronic editor.
2. In Section I, provide the Member Information. Fill in the Member ID, Claim Number, Member Name (Last, First, and Middle Initial), the Date of Service, Billed Amount, and the Patient Name (Last, First). If the patient name is the same as the member name, indicate this clearly.
3. Proceed to Section II to fill out the details of the Practitioner, Hospital, or Other Healthcare Provider. Enter the Tax Identification Number (TIN), Phone Number, Physician Name (Last, First, MI), Email Address, Street Address, City, State, Zip Code, Facility/Group Name, and Contact Person.
4. In Section III, enter the details of the person completing the form. Provide their Name, Phone Number, and Email Address.
5. Select the reason for the reconsideration request from Section IV by marking the appropriate checkbox. Include any relevant comments that clarify the nature of your request.
6. If needed, attach any required supporting documentation. Examples of attachments include a copy of the RA or EOB and any other relevant documents specified in the instructions.
7. Once you have filled out all sections and attached required documentation, review the form for completeness. Ensure that all fields are accurately filled and that no information is missing.
8. After reviewing, save your changes and choose to download or print the form for submission. You can share it via the provided email address or mail address as indicated on the form.

Complete your Request For Reconsideration form online today to ensure a timely review of your claims.