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How do I fill this out?
To fill out this form, gather all necessary information regarding the benefit denial. Complete each section with accurate details and sign where required. Finally, submit the form as instructed.
How to fill out the Regence Group Administrators Appeal Submission Form?
1
Gather your Member ID and relevant documents.
2
Complete all sections of the form accurately.
3
Specify the reason for your appeal in detail.
4
Sign the form and date it accordingly.
5
Submit the completed form to Regence Group Administrators.
Who needs the Regence Group Administrators Appeal Submission Form?
1
Patients whose benefits have been denied need this form.
2
Authorized representatives assisting patients with appeals require this form.
3
Health care providers submitting urgent care appeals use this form.
4
Administrators overseeing benefits who need to track appeals might use this form.
5
Individuals preparing for external reviews or legal actions need this form.
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What are the instructions for submitting this form?
To submit the completed appeal form, please return it by mail or fax to Regence Group Administrators. Mail the form to RGA, Attn: Appeals Department, PO Box 52730, Bellevue WA 98015. Alternatively, you can fax the appeal to 1-855-462-8875. Ensure that all required fields are filled out and that you attach any necessary documentation.
What are the important dates for this form in 2024 and 2025?
Important dates for the use of this form include deadlines for submitting appeals which must be completed within 180 days of the notice of denial. Please check the specific year’s guidelines for any updates, especially for 2024 and 2025.
What is the purpose of this form?
The purpose of the Regence Group Administrators Appeal Submission Form is to allow members to formally contest the denial of benefits. This process is critical for patients who believe their claims were unjustly denied, ensuring they have a fair opportunity for review. By submitting this form, members can provide necessary documentation and reasons for their appeal to facilitate reconsideration.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: The full name of the patient appealing the decision.
- 2. Member ID Number: The unique identification number for the member.
- 3. Address: The residential address of the patient.
- 4. Phone Number: Contact number for the patient.
- 5. Group Name/Group Number: Identification information for the patient's group plan.
- 6. Claim Number(s): The unique number associated with the denied claim.
- 7. Case (authorization) Number: The authorization number for the services being appealed.
- 8. Date of Notice of Benefit Denial: The date the patient was notified of the denial.
- 9. Authorized Representative: Details if an authorized representative is appointed to assist.
- 10. Physician Certification: Certification from the physician regarding urgency if applicable.
What happens if I fail to submit this form?
Failure to submit this form can result in the forfeiture of your right to appeal the benefits denial. This means you could lose the opportunity for any further review of the adverse determination. Timely submission is crucial to ensure your claims are considered.
- Loss of Appeal Rights: Failure to submit on time bars any further review of the case.
- Potential Financial Hardship: Not appealing could lead to significant out-of-pocket costs for denied services.
- Lack of Treatment Access: Denial could hinder access to necessary medical treatments.
How do I know when to use this form?
- 1. Immediate Appeal: Used when a benefit has been denied and immediate action is required to appeal.
- 2. Urgent Care Situations: Applicable in situations where urgent treatment is needed and benefits are denied.
- 3. External Reviews: Necessary for initiating external reviews of benefit decisions.
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Is this form valid for external review?
Yes, this form can be used to initiate external review processes depending on your needs.
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