Provider Claims Reconsideration Form

Providers must use this form to submit all necessary information to have a claim reconsidered. Please note this form will reset after 15 minutes of inactivity for security purposes. Review Instructions before completing.

Fields with an asterisk ( * ) are required.

Date of Original Claim Determination (MM/DD/YYYY) * 

Please enter the response date from your Proof of Timely Filing if this is an original claim submission requiring timely filing review.

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February 2020

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Rendering Provider Information

Attention: Please ensure you provide the RENDERING Provider NPI, TIN, Name and Address. Please do not provide Group information in this section. Failure to provide the correct NPI for the Rendering Provider listed on the claim, may result in delays.

Provider Name * 

National Provider Identifier (NPI) *

Provider Tax Identification # (TIN) *

Provider E-Mail Address * 

All communication, receipt confirmation, decision review and outcomes will be sent to email entered.

Provider Street Address *

Provider City *

Provider State *

(Select One) Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marian Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas TW Multi-State U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Provider ZIP Code *

Veteran Information

Veteran Last Name *

Veteran First Name *

Veteran SSN or ICN*

(Select One) Veteran SSN Veteran ICN

Veteran SSN*

Veteran ICN* 

Please omit leading and trailing zeros in ICN.

Veteran Date of Birth (MM/DD/YYYY) *

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February 2020

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Claim Information

Urgent Care (If box is checked the VA Authorization # will not be required.)

VA Authorization # *

Claim # * 

Please enter TF999 if this is an INITIAL claim Submission requiring timely filing review.

Authorizing VAMC

(Select One) ALBANY VAMC ALBUQUERQUE VAMC ALEXANDRIA VAMC ALTOONA VAMC AMARILLO VAMC ANCHORAGE VAMC ANN ARBOR VAMC ASHEVILLE VAMC ATLANTA VAMC AUGUSTA UPTOWN VAMC AUGUSTA VAMC BALTIMORE VAMC BATAVIA VAMC BATH VAMC BATTLE CREEK VAMC BAY PINES VAMC BECKLEY VAMC BEDFORD VAMC BIG SPRINGS VAMC BILOXI VAMC BIRMINGHAM VAMC BOISE VAMC BONHAM VAMC BOSTON VAMC BROCKTON VAMC BRONX VAMC BROOKLYN VAMC BUFFALO VAMC BUTLER VAMC CANADAIGUA VAMC CASTLE POINT VAMC CHARLESTON VAMC CHEYENNE VAMC CHICAGO VAMC CHILLICOTHE VAMC CINCINNATI VAMC CLARKSBURG VAMC CLEVELAND VAMC COATESVILLE VAMC COLUMBIA VAMC MISSOURI COLUMBIA VAMC SOUTH CAROLINA COLUMBUS VA VAMC DALLAS VAMC DANVILLE VAMC DAYTON VAMC DENVER 1 VAMC DENVER VAMC DES MOINES VAMC DETROIT VAMC DUBLIN VAMC DURHAM VAMC EAST ORANGE VAMC EL PASO VAMC ERIE VAMC FARGO VAMC FAYETTEVILLE VAMC ARKANSAS FAYETTEVILLE VAMC NORTH CAROLINA FORT MEADE VAMC FORT THOMAS VAMC FORT WAYNE VAMC FRESNO VAMC GAINESVILLE VAMC GRAND ISLAND VAMC GRAND JUNCTION VAMC GREATER LOS ANGELES VAMC HAMPTON VAMC HARLINGEN VAMC HINES VAMC HONOLULU VAMC HOT SPRINGS VAMC HOUSTON VAMC HUNTINGTON VAMC INDIANAPOLIS VAMC IOWA CITY VAMC IRON MOUTAIN VAMC JACKSON VAMC JACKSONVILLE VAMC KANSAS CITY VAMC KERRVILLE VAMC LAKE CITY VAMC LEAVENWORTH VAMC LEBANON VAMC LEXINGTON COOPER VAMC LEXINGTON VAMC LITTLE ROCK VAMC LIVERMORE VAMC LOCH RAVEN VAMC LOMA LINDA VAMC LONG BEACH VAMC LOUISVILLE VAMC LYONS VAMC MADISON VAMC MANCHESTER VAMC MANHATTAN VAMC MARION VAMC ILLINOIS MARION VAMC INDIANA MARTINEZ 1 VAMC MARTINSBURG VAMC MEMPHIS VAMC MENLO PARK VAMC MIAMI VAMC MILWAUKEE VAMC MINNEAPOLIS VAMC MONTANA VAMC MONTGOMERY VAMC MONTROSE VAMC MOUNTAIN HOME VAMC MURFEESBORO VAMC MUSKOGEE VAMC NEW ORLEANS VAMC NEWINGTON VAMC NORTH CHICAGO VAMC NORTH LITTLE ROCK VAMC NORTHAMPTON VAMC NORTHERN CA HCS SACRAMENTO VAMC NORTHPORT VAMC OKLAHOMA CITY VAMC OMAHA VAMC ORLANDO VAMC PALO ALTO VAMC PERRY POINT VAMC PHILADELPHIA VAMC PHOENIX VAMC PITTSBURGH HJH VAMC PITTSBURGH VAMC POPLAR BLUFF VAMC PORTLAND VAMC PRESCOTT VAMC PROVIDENCE VAMC PUGET SOUND HCS AMERICAN LAKE VAMC PUGET SOUND HCS SEATTLE VAMC RENO VAMC RICHMOND VAMC ROSENBURG VAMC SACRAMENTO VAMC SAGINAW VAMC SALEM VAMC SALISBURY VAMC SALT LAKE CITY VAMC SAN ANTONIO VAMC SAN DIEGO VAMC SAN FRANCISCO VAMC SAN JUAN VAMC SHERIDAN VAMC SHREVEPORT VAMC SIOUX FALLS VAMC SOUTHERN NEVADA VA HCS VAMC SPOKANE VAMC ST CLOUD VAMC ST LOUIS JB VAMC ST LOUIS VAMC SYRACUSE VAMC TAMPA VAMC TEMPLE VAMC TENNESSEE VALLEY VAMC TOGUS VAMC TOMAH VAMC TUCSON VAMC TUSCALOOSA VAMC TUSKEGEE VAMC VANCOUVER VAMC WACO VAMC WALL WALLA VAMC WASHINGTON DC VAMC WEST HAVEN VAMC WEST PALM BEACH VAMC WEST ROXBURY VAMC WHITE CITY SORCC VAMC WHITE RIVER JUNCTION VAMC WICHITA VAMC WILKES BARRE VAMC WILLMINGTON VAMC

Date of Authorization Validity Start (MM/DD/YYYY)

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February 2020

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Date of Authorization Validity Expiration (MM/DD/YYYY)

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February 2020

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Date of Service Start (MM/DD/YYYY) *

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February 2020

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Date of Service End (MM/DD/YYYY)

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February 2020

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Reconsideration Request Explanation *

Describe your concern(s) regarding the outcome of the claim. Please provide details to support your Reconsideration Request. Be as specific as possible and try to describe events in the order in which they occurred. If you are requesting reconsideration on a timely filing denial, please attach supporting documentation (maximum of 3 attachments). Don't include medical records in your submission (if medical records are required, we will request them directly).

To continue with the information as entered, click OK. To review or edit it, click Cancel.