Claims Second-Level Reconsideration Form

REQUEST FOR PROVIDER RECONSIDERATION

If you disagree with the First-Level Review, please use this form to submit a Second-Level Reconsideration including additional information that may change the outcome from the initial decision.
Requests for a first-level review or adjustment must be made within:
•  24 months of our process date for commercial claims
•  12 months from the date of service for Medicare claims
•  30 months for any claims related to coordination of benefits
Please complete the fields below and fax this form with supporting documentation to:
Attention: Claims Second-Level Reconsideration
509-241-7615
Today’s Date /
Call Reference Number from 1st Level Review /
Member's Name /
Member's Consumer number /
Claim Number(s) /
Provider Name & Address /
Contact Name, Phone Number & Fax Number /
Reason for Reconsideration /