REQUEST FOR CLAIM RECONSIDERATION Log#
REQUEST FOR CLAIM RECONSIDERATION Log#: This form and accompanying documentation MUST be submitted 60 days from the date on the Explanation of Payment (EOP).Retain a copy of reconsideration for your records. RECONSIDERATIONS SUBMITTED WITHOUT ALL OF THE NECESSARY DOCUMENTATION AND/OR AFTER THE 60-DAY LIMIT HAS EXPIRED, ARE NOT …
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