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Provider Claims Reconsideration

Submit a claim reconsideration when you believe the claim originally submitted and processed was complete and accurate, but you disagree with the claim determination and are requesting a secondary review.

IMPORTANT! Please review the types of claims submissions below. Follow the appropriate steps to prevent delays in reviewing your request. The instructions differ based on the type of submission.

Important Instructions Before Submitting
Action/Request Purpose Additional Info Next Step
Claim Reconsideration Form To dispute the outcome of a previously submitted and processed claim. Claim information originally submitted was complete and accurate (to your knowledge) and you are requesting a secondary review. PROCEED! Complete the form as instructed below.
Corrected Claim To replace a previously submitted and processed claim. A corrected claim might include providing a referral number or rendering NPI originally omitted, different procedure(s) or diagnosis codes, or any other information that would change the way the claim was originally processed. STOP! Do not use this Claims Reconsideration Form. – Follow standard Corrected Claims submission procedures as found in the CCN Provider Handbook.
Voided Claim To cancel an already submitted and processed claim. A voided claim must be identical to the original claim that it is intended to cancel. STOP! Do not use this Claims Reconsideration Form. – Follow standard Voided Claims submission procedures as found in the CCN Provider Handbook.

Proceed to submit an Online Claim Reconsideration Form.

Claims Reconsiderations Guidelines

DO

  • Do submit a reconsideration form for each individual claim.
  • Do complete ALL fields in the reconsideration form.
  • Do provide a clear and detailed explanation to support your reconsideration request.
  • Do include supporting documentation such as proof of timely filing and a claim image when submitting timely filing reconsiderations.

DON'T

  • Don’t include documentation that is not relevant to the claim being reconsidered.
  • Don’t include medical records in your submission (if medical records are required, we will request them directly).
  • Don’t submit multiple claims on one reconsideration form (will be rejected).
  • Don’t use or submit this form if your intent is to submit a Corrected or Voided Claim.

Important — Timely Filing!

  • Verify the date of original claim payment or denial, prior to proceeding with the remaining instructions. Reconsideration Forms must be submitted within 90 days of the original claim processed date.
  • Reconsideration Forms submitted outside of the timely filing period will be denied accordingly.
  • Incomplete/invalid Reconsideration Forms received within the 90-day timely filing period will be rejected.
  • A rejected Reconsideration Form is not considered “timely”. You must submit a COMPLETE and VALID Reconsideration Form within the 90-day period for it to be accepted and reviewed as “timely”.

How to File a Claim Reconsideration

Submit Electronically: Please complete the Online Provider Claims Reconsideration Form.

Submit by Mail: Download TriWest’s Provider Claims Reconsideration Form and print. Send the completed form with a copy of the claim image to the address provided on the form.

Updated: 5/30/2024 11:13:27 AM