Provider COB Resubmission Appeal Form Instructions
This document provides a comprehensive guide for submitting appeals, COB resubmissions, and reconsiderations to Fidelis Care. It outlines the necessary information required and procedures to follow to ensure proper processing. Users should carefully review this file to understand the requirements for their claims adjustments.
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How do I fill this out?
To fill out this form, begin by gathering all necessary information related to the claim. Ensure that each field is completed accurately to avoid delays in processing. Finally, double-check your entries before submitting the form to Fidelis Care.
How to fill out the Provider COB Resubmission Appeal Form Instructions?
1
Gather necessary claim information.
2
Complete all required fields accurately.
3
Include relevant supporting documents.
4
Review the form for accuracy.
5
Submit the form to Fidelis Care.
Who needs the Provider COB Resubmission Appeal Form Instructions?
1
Healthcare providers submitting claims to Fidelis Care.
2
Patients disputing a coverage decision made by Fidelis Care.
3
Administrative staff handling claims for healthcare facilities.
4
Insurance coordinators managing COB situations.
5
Individuals needing to correct claim information.
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Open the PDF file in the PrintFriendly editor.
2
Navigate to the section you want to edit.
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5
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What are the instructions for submitting this form?
Submit this form to the appropriate mailing address listed in the document. You can also send it via fax or email if specified. Ensure that you retain a copy of your submission for your records and follow up to confirm receipt.
What are the important dates for this form in 2024 and 2025?
Important dates for submitting this form in 2024 and 2025 will be specified based on the claims processing calendar. Ensure to stay updated with any changes from Fidelis Care regarding submission deadlines. Regularly check for notifications from your healthcare provider.
What is the purpose of this form?
The purpose of this form is to collect essential information from providers and members to address issues related to claim denials, incorrect data submissions, and coordination of benefits situations. It serves as a formal request for reconsideration, allowing users to present their case effectively. Ultimately, this form aims to facilitate transparency and ensure proper handling of claims-related disputes.
Tell me about this form and its components and fields line-by-line.
- 1. Member Name: The full name of the member filing the appeal or resubmission.
- 2. Member ID: A unique identifier assigned to the member by Fidelis Care.
- 3. Claim Number: The reference number for the claim being disputed.
- 4. Date of Service (DOS): The date when the service was provided.
- 5. Provider Name: The name of the healthcare provider associated with the claim.
- 6. NPI or TIN: National Provider Identifier or Tax Identification Number of the provider.
- 7. Name of Requestor: Name of the individual submitting the form.
- 8. Date of Request: The date when the request is being submitted.
- 9. Request Type: Indication of whether the request is for COB, Appeal, or Reconsideration.
- 10. Description of Request: A brief explanation of the reason for the appeal or resubmission.
What happens if I fail to submit this form?
Failure to submit this form accurately may lead to delays or denial of your claim reconsideration or appeal request. It is crucial to complete all required fields and provide supporting documentation. Any missing information could result in your appeal being dismissed.
- Incomplete Information: Failure to fill out all required fields may halt the processing of your request.
- Missed Deadlines: Submissions after the deadline can lead to automatic denial of your appeal.
- Insufficient Documentation: Not including necessary documents can undermine the validity of your claim.
How do I know when to use this form?
- 1. Denial Appeal: To contest a coverage decision that you disagree with.
- 2. COB Resubmission: To provide additional data for claims related to coordination of benefits.
- 3. Reconsideration Request: When initial submissions contained errors or incomplete information.
Frequently Asked Questions
How do I complete the Appeal Form?
Follow the instructions provided in the form to fill out all necessary fields and submit any supporting documents.
Can I edit this PDF online?
Yes, PrintFriendly allows you to edit PDFs directly in the browser before downloading.
What information do I need to provide?
You must include member name, ID, claim number, and the reason for the resubmission or appeal.
How do I submit this form?
You can submit it via mail to the designated address mentioned in the form.
What if I need to correct my submission?
You can use this form again to send the corrected information to Fidelis Care.
Is there a deadline for submission?
Yes, all requests must be submitted within 60 days from the remittance date.
Can I save my changes in PrintFriendly?
Currently, you can edit and download your PDFs, but you cannot save them directly on the site.
What should I do if my claim is denied?
Use this form to file an appeal against the denial.
Who can assist me with this process?
Administrative staff at your healthcare provider's office can help guide you through the process.
Are there any fees for submitting this form?
No, there are no fees associated with submitting this form to Fidelis Care.
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