CLAIM RECONSIDERATION FACE SHEET INSTRUCTIONS
Claim Reconsideration Face Sheet
1. Each claim reconsideration is to be submitted in writing with the "Claim Reconsideration Face Sheet" form and supporting attachments listed under each category "Reason for Reconsideration."
2. Reconsideration's and attachments can be mailed or faxed to:
Seton Health Plan Service Benefit Administrators
P.O. Box 14545
Austin, TX. 78761
Phone: (512) 421-5667
Fax: (512) 421-4860
3. Required fields to be completed:
· Submitting person's name, phone and fax number
· Claim number
· Reason for reconsideration
· Applicable attachments
· Member name and ID number
4. Incomplete requests will result in claim reconsideration rejection.
5. Resubmissions and Claims Status Checks are not appeals. Call Customer Service at (512) 421-5667 for claim status checks.