When health care providers face denials from Coventry Health Care of Delaware, Inc., for various reasons such as the denial of services due to judgments of medical necessity, determinations regarding cosmetic or experimental procedures, patient eligibility issues, or even untimely filings, the Coventry Appeals Form becomes a crucial tool for contesting these decisions. This form, detailed for both clinical and administrative appeals, requires providers to indicate the specific nature of their appeal, whether it be challenging a clinical judgment or an administrative decision. Critical to this process is the adherence to Delaware State Regulations, which mandate that providers can only submit appeals on behalf of a member with a duly completed HIPAA form, underlining the importance of privacy and authorization in the appeals process. Moreover, the form is designed to facilitate both the submission of claims payment disputes and the necessary authorization for providers to act as representatives during the appeal. Providers are guided to provide comprehensive information regarding the appeal, including member details, service dates in question, and additional relevant information to ensure a thorough review. The personal touch is not lost; instructions on how to complete and where to submit the appeal, including the options for fax and verbal communication, are clearly spelled out, ensuring that providers have a clear pathway to seek redress for both themselves and their patients. This document not only serves as a medium for challenging denials but also as a testament to the structured, yet flexible approach to ensuring fair review and resolution of disputes within the healthcare insurance landscape.
| Question | Answer |
|---|---|
| Form Name | Coventry Appeals Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | coventry health printable appeal forms, coventry of ga reconsideration, coventry appeal form florida, coventry appeal form |
Provider Appeal/Grievance Request Form
Commercial
MAIL TO: |
|
Coventry Health Care of Delaware, Inc. |
Providers Name: __________________ |
Attn: Appeals Coordinator |
Providers Address: ________________ |
750 Prides Crossing |
Contact Name: ___________________ |
Suite 300 |
Phone Number:___________________ |
Newark, De 19713 |
|
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.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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
750 Prides Crossing, Suite 300
Newark, DE 19713
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: _________