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.

Timely Filing Reconsideration Requests require supporting documentation. You may attach up to 3 documents, on the following page.

Rendering Provider Information

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.

Veteran Information

Claim Information

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).

0 / 4000

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