Transcription of Claims Review Request Form Instructions - …
{{id}} {{{paragraph}}}
Example: barber
Claims Review Request Form Instructions - …
Claims Review Request form Instructions 10/8/2018 Page 1 The Claims Review Request form can be filled out online and printed. Review requests must be mailed. Please do not fax the form . 1. *Date: Enter the date this form was filled out. 2. *Check the applicable box for the type of Request : a. claim Review Request -Reviewed by DXC Technology Claims department b. Medicaid Request -Reviewed by DHW Please refer to the section on claim Review Request in the Idaho MMIS Provider Handbook, General Billing Instructions . 3. * claim ID to Review : This is the unique 13 or 15 (adjustment claim ending with an A#) digit claim identification number. This can be found under the member s name on the RA or in the claim ID field online. Only indicate one claim number per form . 4. Case # (if applicable): This is the unique 13 digit identifier given for each Review Request .
Claims Review Request Form Instructions 10/29/2014 Page 1 The Claims Review Request Form can be filled out online and printed. Review requests must
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: