Edit, Download, and Sign the Molina Healthcare Claim Reconsideration Request Form
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How do I fill this out?
To fill out this form, ensure all required fields are completed and supporting documents are attached. The form must be filled accurately to avoid processing delays. Refer to the instructions for more detailed guidance.
How to fill out the Molina Healthcare Claim Reconsideration Request Form?
1
Complete the contact person information.
2
Fill in provider and member details.
3
Provide claim and business information.
4
Check the applicable denial reasons.
5
Attach supporting documentation and submit the form.
Who needs the Molina Healthcare Claim Reconsideration Request Form?
1
Healthcare providers needing to request reconsideration for a denied claim.
2
Billing departments handling claim disputes.
3
Medical offices submitting corrected claims for payment.
4
Insurance specialists managing overpayment or underpayment cases.
5
Claims administrators addressing coordination of benefits issues.
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What are the instructions for submitting this form?
Submit the completed form along with supporting documents either electronically via the Provider Portal or by faxing to (800) 499-3406. Ensure all details are accurate to avoid any delays in processing. It's advised to refer to the Molina Provider Manual for specific deadlines and guidelines for submission.
What are the important dates for this form in 2024 and 2025?
Please refer to the Molina Provider Manual for specific deadlines and timelines applicable for submissions in 2024 and 2025.
What is the purpose of this form?
The Molina Healthcare Claim Reconsideration Request Form is designed for healthcare providers to request a review of denied claims. This form ensures that all necessary information is captured accurately to facilitate the reconsideration process. By using this form, providers can address various issues such as duplicate services, incorrect member processing, eligibility, and more, thereby ensuring accurate claim handling.
Tell me about this form and its components and fields line-by-line.
- 1. Contact Person: Name of individual submitting the request.
- 2. Provider/Group Name: Name of the healthcare provider or group.
- 3. Provider NPI: National Provider Identifier of the healthcare provider.
- 4. Provider Phone #: Contact phone number for the provider.
- 5. Member Name: Name of the member associated with the claim.
- 6. Member Date of Birth: Date of birth of the member.
- 7. Line of Business: Business line such as Medicaid, Medicare, etc.
- 8. Claim Information: Details of the original claim submission.
- 9. Molina Original Claim ID: ID assigned to the original claim by Molina.
- 10. Original Claim Amount Billed: Total amount billed in the original claim.
- 11. Dates of Service: Dates when the services were provided.
- 12. Provider Information: Additional provider details including tax ID and fax number.
- 13. Member Information: Member's account number and Molina member ID.
- 14. Denial Reason: Reason(s) for claim denial, to be marked by the submitter.
What happens if I fail to submit this form?
Failure to submit this form correctly will result in processing delays or the denial of the reconsideration request.
- Form Returned: Incomplete forms will be returned to the submitter.
- Payment Delays: Incorrect or missing information can delay claim payment.
- Denied Reconsideration: Failure to provide required documents may lead to denial of the reconsideration request.
How do I know when to use this form?
- 1. Duplicate Service: Request reconsideration for claims denied due to duplicate services.
- 2. Incorrect Provider/Tax ID: Address claims processed under the incorrect provider or tax ID.
- 3. Overpayment/Underpayment: Submit for claims involving overpayment or underpayment.
- 4. Timely Filing Limit: Request reconsideration for claims denied due to exceeding the timely filing limit.
- 5. Incorrect NDC: Address claims denied due to missing or incorrect National Drug Code (NDC).
Frequently Asked Questions
How do I fill out the Molina Claim Reconsideration Form?
Complete all required fields with accurate information and attach supporting documents. Submit via fax, portal, or other specified methods.
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PrintFriendly allows you to add an electronic signature directly within the PDF editor.
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Yes, you can email the form or generate a shareable link using PrintFriendly.
What information do I need to provide?
You need to provide contact information, provider and member details, claim information, and select the denial reasons.
What should I do if the form is incomplete?
Incomplete forms will be returned, so ensure all required fields are filled correctly and all necessary attachments are included.
How do I submit the form?
Submit the form through the provider portal, fax, or as specified in the instructions.
Can I request reconsideration for multiple claims?
Yes, attach an Excel sheet with multiple claims having the same denial reason.
How do I know the claim review outcome?
You will be notified of the decision after submission and review of the form.
Where do I find more information?
Refer to the Molina Provider Manual for detailed guidelines and timeframes.
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