Claim Reconsideration Request Form To request a reconsideration review of a previously denied claim, the following item is required for each individual claim: ✓ Medical notes Reason for Reconsideration* MEDNT - Denied - Send Supporting Med Note For Add'l Review MNRQR - Denied - Med Notes Request For Modifier Review MUE - Denied - Per Medicare’s Medically Unlikely Edits, the units of service billed exceed the allowed units billed MUTEX - Denied - Mutually Exclusive To Other Svc Same Day PRNOT - Denied - Please Submit Notes For Review Other Any Other Reason* Member InformationEnter Member ID and Date of Birth to validate Member before proceeding with the form.Member ID* Member DOB* MM slash DD slash YYYY Date of Service Start* MM slash DD slash YYYY Date of Service End* MM slash DD slash YYYY Member Name* First Last Error Message Claim number* Provider InformationGroup Billing NPI* 10 digitsGroup Billing Name* Error Message Contact Name* Contact Email* Phone Number*Description*File Upload. Reconsideration requests with claims attached will be returned to the sender.* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 24 MB. CAPTCHA