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Sample letter of appeal for reconsideration insurance claims pdf

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The document is a CLAIM CORRECTION / RECONSIDERATION FORM for Coventry Health Care of Iowa, Inc. and Advantra, designed for submitting corrected claims, proof of timely filing, and requests for reconsideration regarding denied services. It includes sections for member information, claim details, and a Medicare Member Designated Representative Form that allows members to authorize someone to access their personal health information. The form emphasizes confidentiality and the legal implications of sharing health information.

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