Certification initial 2026

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The document is a Request for Claim Reconsideration form that must be submitted within 60 days of the Explanation of Payment (EOP). It outlines the necessary information and documentation required for reconsideration, including provider details, member information, and reasons for reconsideration. Claims submitted without complete documentation or after the deadline will be returned. The form must be sent to the Geisinger Health Plan Claims Department.

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Click ‘Get Form’ to open the certification initial in the editor.
Begin by entering your PROVIDER NAME and DATE PREPARED at the top of the form. Ensure that these details are accurate for proper identification.
Fill in your TAX ID and HEALTH PLAN PROVIDER #, followed by your TELEPHONE #. This information is crucial for communication regarding your claim.
Next, provide MEMBER NAME, DOS (Date of Service), MEMBER ID #, and PATIENT ACCOUNT #. Each field must be completed to ensure a smooth reconsideration process.
In the PROVIDER COMMENTS section, add any relevant notes that may assist in the reconsideration review.
Select the REASON FOR CONSIDERATION by checking the appropriate box and attach any necessary documentation as specified.
Finally, submit the completed form to the Claims Department at Geisinger Health Plan using the provided address.

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