Use this form as part of the Appeal / COB/ Reconsideration process to address a previous claims adjudication decision.
NOTE: All claim requests for reconsideration and claims disputes must be received within 60 calendar days, or per your contract terms, from the date of the remittance. All fields below are required information. Failure to complete this form in its entirety may result in a delay or denial of your reconsideration/appeal request.
Do not use this form if submitting a Corrected Claim that does not require supporting documentation.
Please refer to the information below when deciding whether to select COB Resubmission, Appeal, or Reconsideration:
COB Resubmission
You are resubmitting a claim that is Coordination of Benefits (COB) related and supporting data. Examples include but are not limited to:
- Copy of claim form and Primary Explanation of Benefits (EOB) from another payer
- Copy of claim form and Copy of Subrogation or Worker’s Compensation Notice of Decision
- Copy of claim form and Copy of other insurance carrier eligibility data.
REQUIRED: Brief description of your reason for the COB Resubmission.
Appeal
The action you take if you disagree with the coverage and/or payment decision. An appeal is a formal written request to Fidelis Care for reconsideration of a medical, payment, or contractual adverse decision. Types of claim denials that would be an appeal include but are not limited to:
- Authorization denial dispute
- Denial requiring medical records
- Clinical edit review
- Invoice pricing dispute
- Claim pricing disputes
- Timely filing dispute
- Surprise Bill
- HSU Appeal
- Other
REQUIRED: Brief description of your reason for the Appeal Request.
Reconsideration
The action you take if the claim(s) was/were originally submitted with incorrect/insufficient information. Examples include but are not limited to:
- Eligibility update
- PCP update
- Retraction Request
REQUIRED: Brief description of your reason for the Reconsideration Request.
Please select “Appeal Status” on our Contact Us Inquiry Form if you require further assistance.