Claim Reconsideration Request Form

A provider may submit a reconsideration request for denied services that require medical documentation for review.
Member Information
Enter Member ID and Date of Birth to validate Member before proceeding with the form.
Member ID*
Member DOB*
MM slash DD slash YYYY
Member Name*
First Last
Error Message
Claim Information
Date of Service Start*
MM slash DD slash YYYY
Date of Service End*
MM slash DD slash YYYY
Claim number*
Are there any unlisted procedure (CPT) codes on this claim?*
- Yes
- No
What unlisted code(s) was/were submitted on this claim?*
What is the closest comparable code for the billed procedure(s)?*
Why is the comparable code incorrect for the procedure?*
Provider Information
Group Billing NPI*

10 digits
Group Billing Name*
Error Message
Contact Name*
Contact Email*
Phone Number*
The rationale for submission of medical documentation should explicitly outline the reason for the reevaluation of the claim:*
File Upload. Reconsideration requests with claims attached will be returned to the sender.*
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 24 MB.
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Member Information