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External Review Application Form

External Review Application Form

 

INSTRUCTIONS: CONNECTICUT REQUEST FOR EXTERNAL REVIEW

 

 

A Connecticut patient who has been denied health insurance coverage for a procedure may request an external review from the state's Insurance Department by using the form discussed in this article. This document can be obtained from the website of the government of Connecticut.

 

Connecticut Request For External Review Step 1: The first section concerns the person who is requesting the external review. Enter your name on the first blank line.

 

Connecticut Request For External Review Step 2: Enter the applicant address on the second blank line.

 

Connecticut Request For External Review Step 3: Enter the applicant daytime phone number on the third blank line.

 

Connecticut Request For External Review Step 4: Enter the applicant email address on the fourth blank line.

 

Connecticut Request For External Review Step 5: Indicate with a check mark whether the applicant is the enrollee or patient, the parent of a minor child under 18, the provider, or a legal or authorized representative.

 

Connecticut Request For External Review Step 6: The second section concerns the enrollee or patient who had their request for medical care denied. Enter their name on the first blank line, their address on the second blank line and their phone number on the third blank line.

 

Connecticut Request For External Review Step 7: The third section concerns the insurance company. Enter the insurance company or health plan name on the first blank line, the subscriber name on the second blank line, the subscriber insurance identification number on the third blank line and the dependent insurance identification number on the fourth blank line.

 

Connecticut Request For External Review Step 8: Indicate whether the coverage is an individual plan, a group plan through an employer, or a group plan through a plan sponsor with a check mark.

 

Connecticut Request For External Review Step 9: The fourth section concerns the provider. Enter the name of the treating physician on the first blank line, their address on the second blank line, the name of a contact person on the third blank line, their email address on the fourth blank line, and their telephone number on the fifth blank line.

 

Connecticut Request For External Review Step 10: Provide an explanation for your appeal where indicated.

 

Connecticut Request For External Review Step 11: Complete the second page as instructed. The third and fourth pages should be completed by the physician.

 

 

Download the PDF file .

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