Michigan Provider's Request for Reconsideration (fill-in form)

• Category: Michigan Workers Compensation - Official
• State: Michigan
• Control #: MI-WC-750
• Format: PDF

Description

Provider's Request for Reconsideration (fill-in form) The Michigan Provider's Request for Reconsideration (fill-in form) is a document used by healthcare providers to appeal denied claims to the Michigan Department of Health and Human Services. This form is used to request a review of a claim to determine if it should be reconsidered for payment. The form provides an overview of the denied claim, the grounds for the appeal, and the requested remedy. The form is available in two versions: an individual provider version and a facility version. Both versions must be completed in full and submitted to the appropriate office. The form must be signed and dated by the provider submitting the request. Once submitted, the Michigan Department of Health and Human Services will review the request and make a determination on whether to approve or deny the reconsideration request.

The Michigan Provider's Request for Reconsideration (fill-in form) is a document used by healthcare providers to appeal denied claims to the Michigan Department of Health and Human Services. This form is used to request a review of a claim to determine if it should be reconsidered for payment. The form provides an overview of the denied claim, the grounds for the appeal, and the requested remedy. The form is available in two versions: an individual provider version and a facility version. Both versions must be completed in full and submitted to the appropriate office. The form must be signed and dated by the provider submitting the request. Once submitted, the Michigan Department of Health and Human Services will review the request and make a determination on whether to approve or deny the reconsideration request.