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Get FL Form 756 2010-2022

Provider Administrative Review Form DirectProvider. com is the preferred method for submitting claim reviews. Submit your dispute within 35 days of your receipt of the Remittance Advice. Product Commercial/Individual Reason Incorrect Claims Payment Request First Second Medicare Medicaid Medical Appeal Third Healthy Kids Long Term Care Reconsideration Claim Number MEMBER INFORMATION Date of request Date s of Service Member Name Member ID PROVIDER INFORMATION Provider Name Tax ID Contact Name Phone Address City State Zip Code Attached EOB Claim RA Medical Records Other Additional Information supporting your dispute P. O. Box 7808 London KY 40742 SUBMIT DISPUTE TO Coventry Health Care of Florida Claim Unit For Medicaid/Healthy Kids For Commercial Submission Guidelines One Claim Reconsideration Form should be used for each claim denial reconsideration and appeal If submitting multiple claims for reconsideration one form will be accepted per reason for review Please include medical records for the dates of service under review Hospitals appealing the denial of inpatient services must submit complete medical records for the member s entire length of stay including physicians orders progress notes therapy notes and ER records as applicable The Provider Manual should be used as a resource for guidelines related to claim reconsiderations denial and appeals available at www. Provider Administrative Review Form DirectProvider. com is the preferred method for submitting claim reviews. Submit your dispute within 35 days of your receipt of the Remittance Advice. Product Commercial/Individual Reason Incorrect Claims Payment Request First Second Medicare Medicaid Medical Appeal Third Healthy Kids Long Term Care Reconsideration Claim Number MEMBER INFORMATION Date of request Date s of Service Member Name Member ID PROVIDER INFORMATION Provider Name Tax ID Contact Name Phone Address City State Zip Code Attached EOB Claim RA Medical Records Other Additional Information supporting your dispute P. Provider Administrative Review Form DirectProvider. com is the preferred method for submitting claim reviews. Submit your dispute within 35 days of your receipt of the Remittance Advice. Product Commercial/Individual Reason Incorrect Claims Payment Request First Second Medicare Medicaid Medical Appeal Third Healthy Kids Long Term Care Reconsideration Claim Number MEMBER INFORMATION Date of request Date s of Service Member Name Member ID PROVIDER INFORMATION Provider Name Tax ID Contact Name Phone Address City State Zip Code Attached EOB Claim RA Medical Records Other Additional Information supporting your dispute P. .

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Keywords relevant to FL Form 756

  • remittance
  • inpatient
  • applicable
  • submitting
  • Coventry
  • ky
  • medicare
  • medicaid
  • submission
  • physicians
  • provider
  • administrative
  • Resource
  • Guidelines
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