In the realm of healthcare, the process of challenging a service denial can be complex, yet it is a critical right held by healthcare providers on behalf of their patients. The Appeal Coventry Healthcare form serves as a vital tool in this process, specifically designed for Coventry Health Care of Delaware, Inc. It outlines the procedural steps for filing two major types of appeals: clinical and administrative grievances, as well as addressing claim payment disputes. Made accessible to providers, the form requests essential information such as the provider's name, address, and the details concerning the service denial, including member name and ID, along with the date(s) of the disputed service. Crucially, to pursue an appeal, providers must comply with Delaware State Regulations, necessitating authorization to represent a member in the appeal process through a completed HIPAA form. This precondition underscores the importance of protecting patient privacy and ensuring that appeals are filed with proper authorization. Furthermore, the document spells out that for certain dispute types, providers must direct their submissions to an alternative address, highlighting the need for attention to specific procedural details. The form, therefore, not only functions as a medium for appealing adverse benefit determinations but also emphasizes the regulatory and procedural nuances integral to the appeals process.
| Question | Answer |
|---|---|
| Form Name | Appeal Form Coventry Healthcare |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | coventry health appeal forms, coventry parc form, coventry health care provider appeal form, parc form for coventry appeal |
Provider Appeal/Grievance Request Form
Commercial
MAIL TO: |
|
Coventry Health Care of Delaware, Inc. |
Providers Name: __________________ |
Attn: Appeals Coordinator |
Providers Address: ________________ |
2751 Centerville Rd. |
Contact Name: ___________________ |
Suite 400 |
Phone Number:___________________ |
Wilmington, DE 19808 |
|
Please indicate your type of Appeal below:
Clinical Appeal/Grievance - Check this box for a denial of services that you believe were based in whole or in part of clinical judgment such as:
∙Per the Delaware State Regulations, Delaware Providers may only appeal as an authorized representative on behalf of the member unless your contract with Coventry Health Care of Delaware, Inc. specifies otherwise. A completed HIPAA form will be required when Delaware Providers submit an appeal on behalf of a member.
∙Medical Necessity denials
∙Cosmetic procedure denials
∙Experimental / Investigational procedure denials
∙Inpatient level of care issues
∙Emergency room services
Administrative Appeal/Grievance - Check this box for a denial you believe was based on
∙Per the Delaware State Regulations, Delaware Providers may only appeal as an authorized representative on behalf of the member, unless your contract with Coventry Health Care of Delaware, Inc. specifies otherwise. A completed HIPAA form will be required when Delaware Providers submit an appeal on behalf of a member.
∙Benefit determination denials
∙Member eligibility post service denials
∙Untimely filing denials
∙Denials for no authorizations
Provider Appeal Form 2010
Claim Payment Disputes – Check this box for denial of services which may include, but are not limited to, claim check edits, the use of modifiers, duplicate claims, assistant surgeon billing, global or incidental codes, etc.
PLEASE NOTE: DISPUTES OF THIS NATURE SHOULD BE SUBMITTED TO THE FOLLOWING ADDRESS AND NOT TO THE WILMINGTON, DE OFFICE:
Coventry Health Care of Delaware, Inc.
P.O. Box 7713
London, KY 40742
Member Name_________________________ Member ID Number_____________________
Date(s) of Service Denied:___________________
Please use the space below to supply any other necessary information, along with your attachment (s), to enable a thorough Appeal/Grievance review.
_____________________________________________________________________________
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_____________________________________________________________________________
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Signature of Sender____________________________________ Date______________
Provider Appeal Form 2010
Member Name: ____________________
Member ID # : __________________
Dates of Service: ________________
Dear Provider,
You recently contacted us, to request an appeal of an adverse benefit determination Coventry Health Care of Delaware Inc. (CHCDE) made related to the above referenced member. In order for you to appeal on behalf of the member, CHCDE is required to receive written or verbal authorization from the member that you are the member’s authorized representative with regard to this matter.
Therefore, we ask that you and the member complete the enclosed authorized representative form and return it to us within 10 days of receipt of the form. Upon receipt of the completed form, we will initiate a review of your appeal. If the completed form is not received within 30 days of this letter, we will consider your request for an appeal as withdrawn. You may send or fax the form to us at:
Coventry Health Care of Delaware, Inc.
ATTN: Appeals Coordinator
2751 Centerville Road, Suite 400
Wilmington, DE 19808
Fax: (866)
The member may also call the Appeals Department at (800)
If you or the Member has any questions, please feel free to call me at number listed above.
Sincerely,
Appeals Coordinator
Provider Appeal Form 2010
Coventry Health Care Of Delaware, Inc.
Authorization For Disclosure Of Personal Health Information
To Appeals Representative
The following person will act on my behalf during appeals related to
_____________________________________________________________________________ (please provide
a brief description of the issue that will be appealed).
Name of person acting on my behalf: |
________________________________________ |
Address of person acting on my behalf: |
________________________________________ |
|
________________________________________ |
Telephone number of person acting on my behalf: __________________________________
I understand that:
∙I may revoke this authorization at any time by sending Coventry Health Care of Delaware, Inc. written notification of my revocation;
∙Revocation of this authorization will not affect any action Coventry Health Care of Delaware, Inc. took in reliance on this authorization before it received my written revocation;
∙This authorization will expire upon the completion of the appeals process;
∙Coventry Health Care of Delaware, Inc. may need to provide my representative with my health information, which may include my protected health information (PHI), so that my authorized representative can participate in the appeals process.
By signing below, I acknowledge that I have read and understand the information above.
Member Name: ______________________________(please print name) Date __________
Member signature:________________________________ Member ID Number: _________