Get Va Form 216-a 2022-2025

Filling out the VA Form 216-A online can be a streamlined process if you follow the necessary steps carefully. This form is crucial for requesting an external review from the Virginia Bureau of Insurance regarding health coverage denials.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the name of the applicant in the designated field. This can be the covered person or an authorized representative.
3. In the ‘Covered Person Information’ section, accurately fill in the name, street address, city, state, zip code, date of birth, and contact number (home and fax).
4. In the ‘Insurance Information’ section, write down the health carrier's name, the covered person's insurance ID number, the insurance claim or reference number, and the health carrier's phone number.
5. If the coverage is through an employer, provide the employer name and their phone number. Determine if the health coverage is a self-funded plan and consult the human resource office if needed.
6. Complete the ‘Health Care Provider Information’ section by providing the name of the treating health care provider, a contact person, their phone number, fax, and email.
7. Check the appropriate reason for the health carrier's denial from the provided options. Be sure to note that other reasons may not be eligible for external review.
8. Include a brief summary of the external review request, describing the health care service or treatment that was denied. Attach the denial letter from the health carrier, if available.
9. If requesting an expedited review, indicate whether the service was provided and have your treating health care provider complete the necessary form confirming that a delay could jeopardize the patient's health.
10. Finally, sign and date the form, consenting to the release of medical records. Ensure that the information provided is accurate.
11. After completing the form, you can save changes, download, print, or share it as necessary.

Complete your VA Form 216-A online today to ensure prompt processing of your external review request.