Fillable Appeal Request Form This form is to be (Minnesota Department of Revenue)

Fill Online, Printable, Fillable, Blank Appeal Request Form This form is to be (Minnesota Department of Revenue) Form

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Appeal Request Form This form is to be (Minnesota Department of Revenue)

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The Appeal Request Form This form is to be (Minnesota Department of Revenue) form is 1 page long and contains:

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  • 11 check-boxes
  • 16 other fields

Country of origin: US
File type: PDF

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Appeal Request Form
This form is to be used when a provider is requesting a reconsideration of a previously adjudicated claim
but there is no additional or corrected data to be submitted.
Payer name and address, allow for formatting in window envelope for paper submission.
Billing Provider Information:
Name:
ID Number:
Patient Account Number:
Claim Information:
Patient Name:
Patient ID Number:
Date(s) of Service:
Payer Claim Number:
Property and Casualty or
Workers Compensation Claim Number:
Reason for Appeal Request:
Timely Filing Pricing Eligibility Medical Policy Code Review Other
Complete description of reason for claim appeal.
Supplemental Documentation:
Remittance Advice Spreadsheet Refund Medical Records
Other (describe):
Contact Information:
Requester: Date:
Individual requesting appeal Date of appeal request
Contact Number:
Phone, fax or email should be supplied for entity requesting appeal
Address:
Mailing address for response
Total number of pages:
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Appeal Request Form This form is to be (Minnesota Department of Revenue)

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Completed 18 May 2021

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