APPEALS AND PAYMENT DISPUTES
REQUEST FORM
Complete the top section of this form completely and legibly. Check the box that most closely describes your appeal or payment
disputes reason. Be sure to include any supporting documentation, as indicated below. Requests received without required
information cannot be processed.
Request for appeal or payment disputes
Customer rst name: MI: Customer last name:
Customer ID #: Customer date of birth (MM/DD/YYYY):
Claim #: Date of service (MM/DD/YYYY):
Provider name/contact name: Provider NPI:
Provider phone #: Provider’s contact email address:
Appeals
Reason for appeal:
Medical necessity
Notication/precertication
• Include precertication/prior authorization number
Referral denial
Payer policy
Submit appeals to:
Fax:
Payment Disputes
Reason for payment dispute:
Payment issue
Duplicate claim
Retraction of payment
Request for medical records
• Include copy of letter/request received
Request for additional information
• Include copy of letter/request received
• Provide missing or incomplete information
- Coding dispute
- Timely ling
• Remittance Advice (RA), Explanation of Benets (EOB),
or other documentation of ling original claim
Coordination of Benets
Submit payment dispute to:
Fax:
Note: If you have multiple payment dispute requests for the same health care professional and payment issue, please indicate
this in the notes below and include a list of the following: Customer ID #, Claim #, and date of service. If the issue requires
supporting documentation as noted above, it must be included for each individual claim. If no additional documentation is
required for your appeal or payment dispute request, fax in only this completed coversheet. You may use the space below to
briey describe your reason for appeal or payment dispute.
Denitions
Payment issue: Was not paid in accordance with the negotiated terms
Coordination of benets: Could not fully be processed until information from another insurer has been received
Duplicate claim: The original reason for denial was due to a duplicate claim
Medical necessity: Medical clinical review
Pre-certication/notication of prior-uuthorization or reduced payment: Failure to notify or pre-authorize
services or exceeding authorized limits
Payer policy clinical: Incorrectly reimbursed because of the payers payment policy
Referral denial: Invalid or missing primary care physician (PCP) referral
Request for additional information: Missing or incomplete information *reply via sender*
Request for medical records: Please include copy of letter/request received
Retraction of payment: Retraction of full or partial payment
Timely ling: The claim whose original reason for denial was untimely ling
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INT_20_84961_C 936591
Attn: Medicare Appeals Unit
Attn: Medicare Claims Department
