Get Cotiviti Discussion Request Form

Filling out the Cotiviti Discussion Request Form online is a straightforward process designed to help you submit a request regarding a healthcare claim. This guide provides step-by-step instructions to ensure you accurately complete the form and support your request effectively.

Follow the steps to successfully complete the form

1. Press the ‘Get Form’ button to access the form and open it in the provided editing tool.
2. Enter your contact information for this request. Provide your fax number, printed name, title/designation, phone number, and extension. Make sure to include a date and provide a signature if required.
3. In the 'Your Request' section, specify the reason for your request in detail. Ensure that it is more than a general statement to facilitate an effective review.
4. Provide the claim number (ICN) and date of service. Be mindful that the format may vary but it should align with the requirements mentioned.
5. Complete the form electronically and print it. Handwritten entries are not accepted.
6. Ensure it is the first page of your submission. Include any supporting evidence that justifies why you believe the services were properly coded and billed.
7. Submit the completed form, ensuring it is carefully reviewed. After submission, you can save changes, download, print, or share the form as needed.

Complete your Cotiviti Discussion Request Form online today to ensure a smooth and efficient processing of your request.