[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288476-105":53,"doc-detail-288476-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","carefirst-federal-employee-program-claim-reconsideration-request-form","CareFirst - Federal Employee Program Claim Reconsideration Request Form","","This formal document serves as a specialized request form for the reconsideration of disputed claims or prior authorization reviews within the CareFirst Federal Employee Program framework. It facilitates the organized collection of critical data points, including policyholder identification, patient details, and specific healthcare provider information. The form is designed to be submitted alongside an official letter of reconsideration and necessary clinical or administrative supporting documentation. It emphasizes adherence to the Service Benefit Plan guidelines, requiring precise date formatting and the inclusion of authorization numbers for accurate claims processing. By providing a structured pathway for members or their authorized representatives, this form ensures that medical necessity and coverage disputes are communicated clearly to the plan administrators for efficient review and resolution within the established benefit framework.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/carefirst-federal-employee-program-claim-reconsideration-request-form/288476/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/carefirst-federal-employee-program-claim-reconsideration-request-form/288476.png","ImageObject",442,249,{"name":88,"@type":89},"Nguyễn Văn Học","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What documents must accompany this form when requesting a claim reconsideration?","Question",{"text":108,"@type":109},"You must attach a letter requesting reconsideration, any relevant supporting documentation, and a completed Federal Employee Program Designation of Representative form if a third party is acting on your behalf.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How should dates be entered on this form?",{"text":113,"@type":109},"All dates must be entered in the mm/dd/yyyy format.",{"name":115,"@type":106,"acceptedAnswer":116},"Where can I find more information regarding the Disputed Claims process?",{"text":117,"@type":109},"Additional information regarding the Disputed Claims process can be found in the Service Benefit Plan brochure.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288476,1789633526,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":4},1374402739827,"https://ap-avatar.wpscdn.com/avatar/14000c97e7351f1a627?x-image-process=image/resize,m_fixed,w_180,h_180&k=1787885694763230660","We request that you complete this form and attach it to your letter requesting reconsideration, along with any supporting documentation, and submit for review. To help CareFirst better understand your request, please complete all sections as fully as possible. See the Disputed Claims process in the Service Benefit Plan brochure for additional information.  \nImportant: Please enter all dates in mm/dd/yyyy format.  \n\n| Reconsideration Request Information |  |  |\n| --- | --- | --- |\n| Today’s Date:   | □ Prior Authorization review request | □ Claim review request |\n\n\n| Policyholder/Member Information |\n| --- |\n| Policy Holder Name (First):   (Last):   Birthdate:  Patient Name (First):   (Last):   Birthdate:  \u003Cbr>Member ID Number: (R)   |\n\n\n| Provider/Facility Information |\n| --- |\n| Provider/Facility Name:  \u003Cbr>Service Address:   City:   State:   Zip:   |\n| Claim number(s) being disputed:  \u003Cbr>Prior Authorization number(s) being disputed:   Date (s) of Service to be Reviewed:   |\n\nImportant: We recommend that you complete and save this form, then submit it to CareFirst, along with your letter of requesting reconsideration, a completed Federal Employee Program Designation of Representative as Authorized Representative for the Disputed Claims Process form if a third party is seeking reconsideration on your behalf, and all relevant supporting documentation. See the Disputed Claims process in the Service Benefit Plan brochure for additional information.","cbCaihnJBD0gagFi","https://ap.wps.com/l/cbCaihnJBD0gagFi","pdf",59719,"English","# Reconsideration Request Information\n## Policyholder and Patient Details\n## Provider and Facility Information\n## Submission and Documentation Instructions","[{\"question\":\"What documents must accompany this form when requesting a claim reconsideration?\",\"answer\":\"You must attach a letter requesting reconsideration, any relevant supporting documentation, and a completed Federal Employee Program Designation of Representative form if a third party is acting on your behalf.\"},{\"question\":\"How should dates be entered on this form?\",\"answer\":\"All dates must be entered in the mm/dd/yyyy format.\"},{\"question\":\"Where can I find more information regarding the Disputed Claims process?\",\"answer\":\"Additional information regarding the Disputed Claims process can be found in the Service Benefit Plan brochure.\"}]","CareFirst - Federal Employee Program Claim Reconsideration Request Form | PDF"]