Provider Reconsideration Request

Claim Reconsideration Request

This form shall be used to request the reconsideration of a claim for which a decision has been issued by Centers Plan and is not intended for claim inquiries or new claims submissions. Be specific when completing the DESCRIPTION OF ISSUE and provide any additional information to support your dispute. Please include a copy of the explanation of payment (EOP) aka remittance advice. For requests that exceed 3 claims, please attach a spreadsheet listing each claim number along with the information listed in the form. For follow up inquiries related to your reconsideration please contact us at 1-844-292-4211. This form is connected to an internal Smartsheet. Please note that access requests will not be granted.

Date

mm/dd/yyyy

Contact Name

Contact Email

Contact Phone

Provider Name

TIN

Provider Specialty

Provider Service Address

Claim ID (1)

Member Name & CPHL ID (1)

DOB (1)

Service From (1)

mm/dd/yyyy

Service To (1)

mm/dd/yyyy

Charges (1)

Prior Paid Amt (1)

Description of Issue (1)

Claim ID (2)

Member Name & CPHL ID (2)

DOB (2)

Service From (2)

mm/dd/yyyy

Service To (2)

mm/dd/yyyy

Charges (2)

Prior Paid (2)

Description of Issue (2)

Claim ID (3)

Member Name & CPHL ID (3)

DOB (3)

Service From (3)

Service To (3)

Charges (3)

Prior Paid (3)

Description of Issue (3)

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