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Appeals must be filed within plan time limits, and only one reconsideration request is allowed per claim, per Provider Manual.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/claims-appeal-reconsideration-request-form/281099/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/claims-appeal-reconsideration-request-form/281099.png","ImageObject",442,249,{"name":42,"@type":43},"Emma Mercer","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-11-05","2026-09-16",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",51,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"How many reconsideration requests can a provider submit per claim?","Question",{"text":63,"@type":64},"Providers are allowed ONE reconsideration request per claim.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What information must be included in the claim appeal/reconsideration request?",{"text":68,"@type":64},"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.",{"name":70,"@type":61,"acceptedAnswer":71},"When must the appeal be filed?",{"text":72,"@type":64},"Appeal/consideration requests must be filed within the number of days specified by the plan; consult the Provider Manual for the specific timeframe.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},281099,1791452270,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":4},962084925502,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","CLAIM APPEAL /RECONSIDERATION REQUEST FORM  \nCLAIM APPEAL /RECONSIDERATION REQUEST FORM  \n* Submit only one claim appeal per form *  \n VISION  DENTAL  \nPLEASE CHECK ONE  \nPlease 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.  \nREQUEST FOR  APPEAL  RECONSIDERATION (PLEASE CHECK ONE) Date    /    /       \nMM DD YYYY  \nRequesting Provider Name  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nRequesting Provider NPI  \n\n|  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nRequesting Provider TIN  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nCLAIM INFORMATION:   \nMember ID Number  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nMember of Birth  \nDate    /    /       \nMember First Name Member Last Name MM DD YYYY  \nDate of Service  \n\n|  |  | / |  |  | / |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nEBO Claim Number  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nMM DD YYYY  \nProcedure/Service Code(s)  \nIndicate the reason( s) for this request ( must select one ) :  \nClaim was denied for no authorization, but authorization number  was obtained.  Claim was denied for untimely filing in error (attach proof of timely filing)  \n Claim was denied for Member not eligible, but member was eligible on DOS (attach eligibility information)  \n Denied as duplicate in error  \n Coordination of Benefits  Other: Please explain below  \nSupporting comments / explanation:  \nSubmitted by  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nDate    /    /       \nPhone  \n\n|  |  |  |\n| --- | --- | --- |\n\n-  \n\n|  |  |  |\n| --- | --- | --- |\n\n-  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\nMM DD YYYY  \nPlease submit form with documentation via Email or Mail to:  \n1. 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 .  \n2. Claims specific corresponsdence from Envolve Benefit Options (authorizations , referrals , etc. ) .  \n3. For coordination of benefit issues , a copy of the other insurance carrier’ s EOB /EOP.  \nVISION CLAIM APPEAL / RECONSIDERATION: DENTAL CLAIM APPEAL / RECONSIDERATION:  \n[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)  \n[MAIL:](MAIL: Envolve Vision)[ Envolve Vision](MAIL: Envolve Vision), Inc. MAIL: Envolve Dental  \nAttn: QI-Appeals Attn: QI-Appeals  \nP O Box 7548 P O Box (refer to Provider Manual) Rocky Mount, NC 2","cbCaieJwWxMG55uG","https://ap.wps.com/l/cbCaieJwWxMG55uG","pdf",1895333,"English","# Request Submission\n## Claim Appeal / Reconsideration Details\n## Claim Information\n## Denial Reason and Supporting Comments\n## Submission Instructions","[{\"question\":\"How many reconsideration requests can a provider submit per claim?\",\"answer\":\"Providers are allowed ONE reconsideration request per claim.\"},{\"question\":\"What information must be included in the claim appeal/reconsideration request?\",\"answer\":\"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.\"},{\"question\":\"When must the appeal be filed?\",\"answer\":\"Appeal/consideration requests must be filed within the number of days specified by the plan; consult the Provider Manual for the specific timeframe.\"}]","Claims Appeal / Reconsideration Request Form | PDF",1789564132]