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Get Geisinger Health Plan Request for Claim Reconsideration 2018

On for your records. RECONSIDERATIONS SUBMITTED WITHOUT ALL OF THE NECESSARY DOCUMENTATION AND/OR AFTER THE 60-DAY LIMIT HAS EXPIRED, ARE NOT ELIGIBLE FOR RECONSIDERATION AND THE HEALTH PLAN WILL RETURN FORM TO PROVIDER’S OFFICE. PROVIDER NAME: DATE PREPARED: TAX ID: PERSON COMPLETING FORM: HEALTH PLAN PROVIDER #: TELEPHONE #: PLEASE SUBMIT ONE MEMBER CLAIM PER RECONSIDERATION FORM MEMBER NAME: DOS: MEMBER ID #: PATIENT ACCOUNT #: Provider Comments: CLAIM #: DOB: REASON FOR CONSID.

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