Fillable PROV02982 PNM Claims Research Form 1 (Passport Health Plan)

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PROV02982 PNM Claims Research Form 1 (Passport Health Plan)

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PROV02982 Updated 3/2019
Provider Network Management
CLAIM RESEARCH FORM
T
o allow us to better serve you, please use this form as a guideline when submitting claim inquiries to your Provider Relations
Representative. This form is not required with your inquiry submission, however the information requested below is pertinent to
our research and will enable us to efficiently resolve inquiries. Please submit each issue type as a separate inquiry and attach
any corresponding spreadsheets as applicable.
Type of issue: Medical Behavioral Health
Please select one of the following:
Incorrect Denial Incorrect Payment per Contract Non-payment Overpayment
Underpayment Authorization PCP Denial Coordination of Benets
Timely Filing Non-Covered Services Copay Other
Did you contact the Provider Claims Service Unit? YES NO
Date of Contact: ________________ Reference/Ticket Number(s): __________________
Supporting Information:
Please complete as applicable
Provider Name: ___________________________
Provider NPI: _____________________________ Provider TIN: ____________________
Member Name: ___________________________ Member ID: _____________________
Date of Service: __________________ Billed Amount: ____________________
Claim ID(s):
_____________________________________________________________________________________________________________
Denial Code(s): _________________________________________________________________________________________________________
CPT/HCPCS(s): __________________________________________________________________________________________________________
Check Number(s): _______________________________________________________________________________________________________
Brief Description of the issue:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
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PROV02982 PNM Claims Research Form 1 (Passport Health Plan)

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Completed 19 July 2020

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