Corrected Claims / Reconsideration Request Form
Requests must be received within 180 days from the date of service (or per the terms of your contract). Please
allow 30 days to process this reconsideration request. Please return this completed form and any supporting
documentation to INTotal Health Plan. Please use a separate request form for each claim reconsideration
request sent to:
INTotal Health
Attn: Provider Claims
P.O. Box 5448
Richmond, VA 23220 – 0448
*Please note, this form should not be used for New Claims or Payment Appeals.
Member Demographic Information
Member ID:
Member Last Name:
Date Form Completed: ___/_____/____
Control/Original Claim#:
Date of Service:
Billed Amount:
_____ /____/_____
$___________
First Name:
MI:
Paid Amount:
$__________
Physician /Health Care Professional Information
Provider’s Name:
Contact Name:
Tax ID Number:
Mailing Address:
Contact Ph#:
NPI Number:
 If this is a Corrected Claim please choose from the following:
☐ Corrected Diagnosis
☐ Corrected Procedure Code (CPT/HCPCS)
☐ Corrected Date of Service
☐ Corrected Charges
☐ Corrected Place of Service
☐ Addition or Correction of Modifier
☐ Corrected Provider Information
☐ Other (Please Specify Below)
 If this is a Reconsideration please choose from the following:
☐ Previously denied / Timely Filing
☐ Previously denied/ duplicate
☐ Previously denied / Additional Information
☐ Previously denied / Not covered
☐ Resubmission: Underpayment
☐ Resubmission: Overpayment
☐Previously denied/ No Authorization
☐ Other (Please Specify Below)
Additional Comments:
Supporting Documentation Attached?
☐ YES
☐ NO