Edit, Download, and Sign the Regence Provider Appeal Form Instructions
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How do I fill this out?
Filling out the Regence Provider Appeal Form is essential to dispute a claim decision. Be sure to provide accurate information to support your appeal case. Gather all relevant documents before starting the process.
How to fill out the Regence Provider Appeal Form Instructions?
1
Download the Regence Provider Appeal Form from the website.
2
Fill out all required fields marked with an asterisk (*) carefully.
3
Provide detailed reasons for your appeal, including relevant documentation.
4
Submit the form via fax or through Availity as required.
5
Confirm submission and await a response from Regence.
Who needs the Regence Provider Appeal Form Instructions?
1
Healthcare providers appealing claim denials.
2
Organizations disputing payment discrepancies with Regence.
3
Facility administrators seeking to clarify claim statuses.
4
Billing departments submitting requests for reconsideration.
5
Patients who want their providers to appeal on their behalf.
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Select the text or fields you wish to edit.
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Type in the correct information or make necessary adjustments.
4
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5
Save your edited PDF or download it for submission.
What are the instructions for submitting this form?
Submit the Regence Provider Appeal Form via fax to 1 (866) 273-1820 or online through the Availity portal. Ensure all required fields are filled out accurately to avoid any delays in processing. If you have questions or need assistance, contact Provider Customer Service for guidance.
What are the important dates for this form in 2024 and 2025?
The Regence Provider Appeal Form is effective from 10/2023. Ensure timely submissions in alignment with any new updates released in 2024 and 2025.
What is the purpose of this form?
The purpose of the Regence Provider Appeal Form is to formally appeal claim decisions made by Regence. It provides a structured approach for healthcare providers to dispute claims on various grounds. By advocating for fair reimbursement, providers can ensure they are compensated appropriately for services rendered.
Tell me about this form and its components and fields line-by-line.
- 1. Name: The name of the provider or the individual submitting the appeal.
- 2. Organization or Provider Name(s): The name of the organization or the health care facility.
- 3. E-mail: Email address for correspondence.
- 4. NPI Number: National Provider Identifier for identification purposes.
- 5. Regence Claim Number: The claim number associated with the appeal.
- 6. CPT/HCPCS: Specific CPT or HCPCS codes related to the services being appealed.
- 7. Date(s) of Service: The date when services were provided.
- 8. Member ID Number: Insurance member identification number.
- 9. Patient Name: The name of the patient related to the claim.
- 10. Phone Number: Contact phone number for communication.
- 11. Fax Number: Fax number for submission of the form.
- 12. Tax ID Number: The Tax Identification Number of the provider.
- 13. Patient Date of Birth: DOB of the patient in MM/DD/YYYY format.
- 14. Total Billed Amount: Total amount billed for the services rendered.
What happens if I fail to submit this form?
Failing to submit the appeal form can result in the denial of your request for reconsideration. It is critical to ensure that all required fields are completed to avoid processing delays. Without the form, the chances of reversing a claim denial are significantly reduced.
- Claim Denial: If the form is not submitted, the initial claim denial stands.
- Delayed Payments: Potential delays in payment can occur if appeals are not properly filed.
- Loss of Revenue: Providers may experience significant revenue loss without successful appeals.
How do I know when to use this form?
- 1. Pre-authorization Disputes: Use this form if pre-authorization was not secured.
- 2. Medical Necessity Denials: Appeal decisions made on the grounds of medical necessity.
- 3. Duplicate Claims: Address issues related to claims marked as duplicates.
- 4. Coding Discrepancies: Challenge decisions based on coding disputes or errors.
- 5. Reimbursement Adjustments: Request additional payment consideration using specific coding modifiers.
Frequently Asked Questions
How do I submit the Regence Provider Appeal Form?
You can submit the form via fax to 1 (866) 273-1820 or through the Availity portal.
What information do I need to provide?
Ensure you fill out all required fields including claim number, patient information, and reason for appeal.
Can I edit the PDF before submission?
Yes, you can edit the PDF to accurately fill out the necessary information.
What happens after I submit my appeal?
You will receive a response from Regence regarding the status of your appeal.
Is there a deadline for submitting an appeal?
Yes, appeals must typically be submitted within a specific timeframe from the decision date.
What if I have questions about the appeal process?
You may contact Provider Customer Service for assistance.
Are there specific guidelines for documentation?
Yes, refer to the Appeals page on Regence's website for suggested documentation.
Can I track my appeal status online?
Providers can check the status of their appeal through the Availity portal.
What types of claims can I appeal?
You can appeal for reasons such as medical necessity denials or coding challenges.
Can patients file appeals themselves?
Typically, it is up to the providers to submit the appeal on behalf of the patients.
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