Transcription of EVV REVIEW REQUEST PROCESS Cigna …
1 1B. Copy of the REQUEST for Refund of Unverified Services of the EVV Claim Refund Summary Pages (part of the letter received)2 Email **ALL REQUESTS MUST INCLUDE COMPLETED REQUEST FORM AND SUPPORTING DOCUMENTS OR WE WILL NOT PROCEED WITH REQUEST **For any questions, please contact Provider Services at: 1-877-653-0331. A provider agency may REQUEST a REVIEW if t he agency seeks to demonstrate that the recoupment should not be initiated. This PROCESS provides you the opportunity to submit accompanying evidence indicating why this recoupment should not be initiated. We will advise you of our decision in writing up to 60 business days of your ApprovedEVV REVIEW REQUEST PROCESSP lease only use this form if you have proof of confirmed EVV transactions to support a recoupment letter you received from Cigna -HealthSpringPlease submit this form with the supporting documents:A.
2 Copy of the EVV visit log from your EVV systemD. Completed EVV REVIEW REQUEST FormSend completed forms to our Customer Service Team at:All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including healthspring Life & Health Insurance Company, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Cigna - healthspring CarePlan is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees. 2018 Cigna Provider Name:Today's date:NPI/TIN: Call ID: Reason Code:Start Date:End of confirmed transaction(s)12. Other Reasons (explain in comments)2345678910111213141516171819202 12223242526272829303132 EVV Visit ID:Reason Code:Comments:EVV REVIEW REQUEST Form Item #Medicaid ID:Member Name:Claim Numbers: Dates of Service.
