Follow the steps to effectively complete the UT Regence 5255UT form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide your contact information in the required fields which include your name, organization or provider name, email, phone number, and fax number. Ensure that all fields marked with an asterisk (*) are completed.
3. Enter your National Provider Identifier (NPI) Number and Tax ID Number. These identifiers are essential for the claims process.
4. Indicate whether the claim(s) has been appealed to Regence before by selecting ‘Yes’ or ‘No’. If you select ‘Yes’, provide a copy of the appeal determination letter.
5. Fill in the Regence Claim Number(s), the specific CPT/HCPCS codes you are appealing, the date(s) of service, member ID number, patient name, and patient date of birth.
6. For claims related to pre-authorization or admission notification denials, select the appropriate reason from the list provided and ensure to include supporting evidence as detailed in the form.
7. Summarize your denial dispute in detail. Clearly articulate your reasons for why the denial should be overturned, and include any supporting documentation.
8. Attach any relevant documentation, such as chart notes or operative reports, to substantiate your request for appeal. Documentation is critical for backing your claims.
9. Once all sections of the form are completed, review your entries carefully for accuracy.
10. You can save your changes, download the form, print, or share it as necessary once finalized.

Complete your UT Regence 5255UT form online today for efficient processing of your appeal.