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Get Allwell Reconsideration Form
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How to fill out the Allwell Reconsideration Form online
Completing the Allwell Reconsideration Form is essential for addressing disagreements regarding claim processing. This guide provides a clear, step-by-step approach to help you fill out the form accurately and effectively online.
Follow the steps to fill out the Allwell Reconsideration Form online.
- Press the ‘Get Form’ button to obtain the Allwell Reconsideration Form and open it in your document editor.
- In the first section, input the provider name and provider tax identification number (Tax ID #). These details help identify the submitting entity.
- Next, enter the control or claim number associated with the claim in question. This information assists in tracking the claim.
- Fill in the date or dates of service related to the claim being reconsidered or disputed. Accurate dates are crucial for the process.
- Provide the member's name and their Member (RID) number, ensuring correct identification of the individual involved.
- Indicate the level of dispute. Select either Level I - Request for Reconsideration or Level II - Claim Dispute based on your situation.
- For Level I, attach any relevant medical records if applicable. If filing a Level II dispute, ensure to include a copy of the Explanation of Payment (EOP) and your original Request for Reconsideration response.
- Select the reason for the dispute by checking the appropriate box. If your reason is not listed, choose 'Other' and provide a brief explanation.
- Lastly, fill in your name, phone number, and the date of the request. This personal information is essential for follow-up communication.
- Once all fields are completed, review your form for accuracy. You can then save changes, download, print, or share the final document.
Complete your Allwell Reconsideration Form online today to ensure your claims are processed correctly.
If you disagree with an action taken by your Medi-Cal managed care plan, you generally must first file an appeal with your managed care plan. You have 60 calendar days from the date of the notice of action to file an appeal with the managed care plan.
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