Claims Appeal / Reconsideration Request Form

Sep 16, 2026

Claims Appeal / Reconsideration Request Form collects provider and member details needed to expedite review of a claim appeal or reconsideration request. Complete the form with requesting provider information, member ID and name, date of service, EBO claim number, and procedure/service codes. Select the denial reason and provide supporting comments with submitted documentation. Appeals must be filed within plan time limits, and only one reconsideration request is allowed per claim, per Provider Manual.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Request Submission

Claim Appeal / Reconsideration Details

Claim Information

Denial Reason and Supporting Comments

Submission Instructions

CLAIM APPEAL /RECONSIDERATION REQUEST FORM CLAIM APPEAL /RECONSIDERATION REQUEST FORM * Submit only one claim appeal per form * VISION DENTAL PLEASE CHECK ONE Please complete the following form to help expedite the review of your claim appeal / reconsideration request. Please email or mail the completed form in full (print or type), with the appropriate documents. Providers are allowed ONE reconsideration request per claim. Appeal / Reconsideration must be filed within the number of days specified by the plan. Please consult your Provider Manual. REQUEST FOR APPEAL RECONSIDERATION (PLEASE CHECK ONE) Date / / MM DD YYYY Requesting Provider Name | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | Requesting Provider NPI | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | Requesting Provider TIN | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | CLAIM INFORMATION: Member ID Number | | | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | Member of Birth Date / / Member First Name Member Last Name MM DD YYYY Date of Service | | | / | | | / | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | EBO Claim Number | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | MM DD YYYY Procedure/Service Code(s) Indicate the reason( s) for this request ( must select one ) : Claim was denied for no authorization, but authorization number was obtained. Claim was denied for untimely filing in error (attach proof of timely filing) Claim was denied for Member not eligible, but member was eligible on DOS (attach eligibility information) Denied as duplicate in error Coordination of Benefits Other: Please explain below Supporting comments / explanation: Submitted by | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | Date / / Phone | | | | | --- | --- | --- | - | | | | | --- | --- | --- | - | | | | | | --- | --- | --- | --- | MM DD YYYY Please submit form with documentation via Email or Mail to: 1. Documentation supporting the appealed / reconsidered claim ( operative reports, medical records, chart notes , etc. ) Documentation must contain information not submitted with the original claim. If no additional documentation is provided , the original disposition will prevail . 2. Claims specific corresponsdence from Envolve Benefit Options (authorizations , referrals , etc. ) . 3. For coordination of benefit issues , a copy of the other insurance carrier’ s EOB /EOP. VISION CLAIM APPEAL / RECONSIDERATION: DENTAL CLAIM APPEAL / RECONSIDERATION: [EMAIL:](EMAIL: Envolve_AppealsandRecons@envolvehealth.com)[ Envolve_AppealsandRecons@envolvehealth.com](EMAIL: Envolve_AppealsandRecons@envolvehealth.com) [EMAIL:](EMAIL: dentalappeals@envolvehealth. com)[ dentalappeals@envolvehealth. com](EMAIL: dentalappeals@envolvehealth. com) [MAIL:](MAIL: Envolve Vision)[ Envolve Vision](MAIL: Envolve Vision), Inc. MAIL: Envolve Dental Attn: QI-Appeals Attn: QI-Appeals P O Box 7548 P O Box (refer to Provider Manual) Rocky Mount, NC 2

FAQs

How many reconsideration requests can a provider submit per claim?

Providers are allowed ONE reconsideration request per claim.

What information must be included in the claim appeal/reconsideration request?

Include requesting provider details, member ID and member information, date of service, EBO claim number, procedure/service codes, denial reason selection, and supporting comments/explanation.

When must the appeal be filed?

Appeal/consideration requests must be filed within the number of days specified by the plan; consult the Provider Manual for the specific timeframe.

Sep 16, 2026

Uploaded by Emma Mercer