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Get Geisinger Health Plan Request for Claim Reconsideration 2020-2023

Rds. Reconsiderations submitted without all the necessary documentation and/or after the 60-day limit has expired are not eligible for reconsideration and will be returned to the provider s office. PLEASE SUBMIT ONLY ONE MEMBER PER CLAIM RECONSIDERATION FORM. Provider name: Date prepared: Tax ID: Person completing form: Provider NPI #: Telephone: Member name: Claim #: DOS: Member Health Plan ID#: Patient account #: DOB: Reason for consideration (choose one): COB Attach copy of.

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