Name: ______________________________ Relationship to Beneficiary________________________ Phone Number: ______________________ If you would like to review the information that is being used in the Reconsideration Review, please call (Insert LME-MCO Telephone Number) and we will send you the information within 7 days. Please see the Medicaid Reconsideration Review Instructions for the conditions that must apply for your services to continue during the Reconsideration Review process. (Insert LME-MCO Telephone Si necesita ayuda con esta forma, por favor llámenos al Number). Diga al operadora que necesita ayuda con Review Request “Reconsideration Form”. (Insert Name of LME-MCO) Reconsideration Review Information and Instructions
Name: ______________________________ Relationship to Beneficiary________________________ Phone Number: ______________________ If you would like to review the information that is being used in the Reconsideration Review, please call (Insert LME-MCO Telephone Number) and we will send you the information within 7 days. Please see the Medicaid Reconsideration Review Instructions for the conditions that must apply for your services to continue during the Reconsideration Review process. Si necesita ayuda con esta forma, por favor llámenos al (Insert LME-MCO Telephone Number). Diga al operadora que necesita ayuda con “Reconsideration Review Request Form”. (Insert Name of LME-MCO) Reconsideration Review Information and Instructions
Admin-Denial-with-Reconsideration-form-and-instructions-12-7-15rr-Final.docx