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A fully completed reconsideration/appeal request form; Fidelis care imposes this requirement with the hipaa authorization form in order to protect our member’s privacy. Web cob related reconsiderations (the claim has previously been billed to fidelis care, and you are requesting a reconsideration or appeal) these will continue to be accepted via paper submission only at this time. How to file.
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Web complete the form below to submit a request for prior authorization. Web the provider appeals form must be used if a claim has been processed and a remittance advice has been issued from fidelis care and the provider is requesting a review. What is an organization determination? A fully completed reconsideration/appeal request form; Fidelis care imposes this requirement with.
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