Coventry Claim Form PDF Details

In the realm of health care administration, precise and efficient communication between providers and insurers is paramount. The Coventry Claim Form embodies one such critical tool for dialogue, serving as a Provider Administrative Review Form that aims to streamline the complex process of claim reviews, disputes, and appeals. Notably, the form is designed for a variety of products including Commercial/Individual, Medicare, Medicaid, Healthy Kids, and Long Term Care, indicating its broad applicability across different health insurance covers. The essence of this form lies in its comprehensive structure, requesting detailed information about member and provider, the nature of the dispute—whether it pertains to an incorrect claims payment, a medical appeal, or a reconsideration request—and specific claim details. Its submission process is made distinct for each insurance product, directing disputes to specialized units within Coventry Health Care of Florida. The guidelines emphasize the form's singular use per claim denial or reconsideration request, the importance of attaching relevant medical records, and adhering to submission deadlines, thereby underscoring the procedural rigour expected in the claims handling process. This form, while a cornerstone in the claims resolution pathway, also underlines the importance of adhering to the specific procedural requirements set forth, including the usage of the provider manual as a fundamental resource. The Coventry Claim Form, with its emphasis on structured information submission and clear guidelines, serves as an essential conduit for resolving disputes, ultimately facilitating a smoother interaction between health care providers and insurers.

Form NameCoventry Claim Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesflorida form administrative review, form provider administrative review, form coventry provider, provider administrative online

Form Preview Example

Provider Administrative Review Form is the preferred method for submitting claim reviews.

Submit your dispute within 35 days of your receipt of the REMITTANCE






Healthy Kids

Long Term Care











Incorrect Claims Payment

Medical Appeal


















Claim Number:_____________________________











Date of request

Date(s) of Service



Member Name

Member ID#




Provider Name




Tax ID






Contact Name














City, State, Zip Code









Other: _____________________________


Medical Records




Additional Information supporting your dispute:


Coventry Health Care of Florida

Claim Unit

For Medicare:

For Medicaid/Healthy Kids:

For Long Term Care:

For Commercial:

P.O. Box 7808

P.O. Box 7403

P.O. Box 7403

P.O. Box 7807

London, KY 40742

London, KY 40742

London, KY 40742

London, KY 40742

Submission Guidelines:

§ One Claim Reconsideration Form should be used for each claim denial, reconsideration, and appeal § If submitting multiple claims for reconsideration, one form will be accepted per reason for review

§ Please include medical records for the dates of service under review

§ Hospitals appealing the denial of inpatient services must submit complete medical records for the member’s entire length of stay, including physicians’ orders, progress notes, therapy notes, and ER records, as applicable

§ The Provider Manual should be used as a resource for guidelines related to claim reconsiderations, denial and appeals (available at

FORM #756 06/2010

How to Edit Coventry Claim Form Online for Free

Filling in coventry appeal form pdf is not hard. Our team designed our tool to make it easy to use and allow you to fill out any form online. Below are a few steps that you should follow:

Step 1: Choose the button "Get Form Here" and click it.

Step 2: At the time you access our coventry appeal form pdf editing page, there'll be each of the actions you may take with regards to your file in the top menu.

All of the following segments are what you are going to complete to get your prepared PDF document.

portion of blanks in coventry health care florida provider appeal form no No Download Needed needed

In the Additional Information supporting, SUBMIT DISPUTE TO Coventry Health, For Medicare For MedicaidHealthy, PO Box London KY, PO Box London KY, Submission Guidelines, One Claim Reconsideration Form, stay including physicians orders, and The Provider Manual should be field, type in your details.

Filling in coventry health care florida provider appeal form no No Download Needed needed part 2

Write the demanded details while you're on the The Provider Manual should be, and Form segment.

step 3 to finishing coventry health care florida provider appeal form no No Download Needed needed

Step 3: Press "Done". Now you can upload the PDF form.

Step 4: It's going to be better to prepare copies of the file. You can be sure that we will not reveal or view your data.

Watch Coventry Claim Form Video Instruction

Please rate Coventry Claim Form

1 Votes
If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .