Claim Reconsideration Request Form

To request a reconsideration review of a previously denied claim, the following item is required for each individual claim:

✓ Medical notes
Reason for Reconsideration*
- MEDNT - Denied - Send Supporting Med Note For Add'l Review
- MNRQR - Denied - Med Notes Request For Modifier Review
- MUE - Denied - Per Medicare’s Medically Unlikely Edits, the units of service billed exceed the allowed units billed
- MUTEX - Denied - Mutually Exclusive To Other Svc Same Day
- PRNOT - Denied - Please Submit Notes For Review
- Other
Any Other Reason*
Member Information
Enter Member ID and Date of Birth to validate Member before proceeding with the form.
Member ID*
Member DOB*
MM slash DD slash YYYY
Date of Service Start*
MM slash DD slash YYYY
Date of Service End*
MM slash DD slash YYYY
Member Name*
First Last
Error Message
Claim number*
Provider Information
Group Billing NPI*

10 digits
Group Billing Name*
Error Message
Contact Name*
Contact Email*
Phone Number*
Description*
File Upload. Reconsideration requests with claims attached will be returned to the sender.*
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 24 MB.
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Member Information