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Click ‘Get Form’ to open the Claim Reconsideration Request Form CRRF in the editor.
In Section 1: General Information, fill in the Claim Number, Member ID, Member Name, Date of Service, Provider Name, Billed Charges, Contact Person, Provider Phone and Fax numbers, NPI, and Provider ID (TIN). Ensure all fields are accurately completed for a smooth processing experience.
Move to Section 2: Type of Claim Adjustment. Check the applicable reason(s) for reconsideration and attach any necessary supporting documentation. This may include medical records or proof of timely filing.
Review your entries for accuracy. Once satisfied, save your changes and prepare to submit the form by mailing it along with any attachments to Molina Healthcare of Puerto Rico as specified.

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See more Claim Reconsideration Request Form CRRF versions

We've got more versions of the Claim Reconsideration Request Form CRRF form. Select the right Claim Reconsideration Request Form CRRF version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2019	4.2 Satisfied (34 Votes)
2015	4 Satisfied (60 Votes)

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