Transcription of DATA ANALYSIS REQUEST FOR INFORMATION …
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DATA ANALYSIS REQUEST FOR INFORMATION …
DATA ANALYSIS REQUEST FOR INFORMATION (RFI). ZPIC Zone 4 TX, OK, NM, CO. REQUEST Type: Data Carrier INFORMATION SVRS-Sample Overpayment Calculation Date of REQUEST : REQUESTOR'S INFORMATION . Requestor Name: Physical Address: Organization: OIG DOJ/FBI OAG/MFCU (required for Strike Force Other: FedEx delivery). Telephone: E-mail: Mobile Phone: Facsimile: Date Required: Check reason for Date Required: Trial Trial Date _____/_____/_____ Other reason: Business Records Affidavit* Is a scanned electronic copy acceptable? Yes No Required?: No Yes *Affidavits are notarized and can delay delivery of data. REQUIRED CRITERIA FOR CLAIMS REQUEST . Type of Data: Medicare Data Only Medicaid Data Only Both Medicare & Medicaid Data Carrier/MAC Documents (see below). Unless otherwise noted below, a standard Data Summary Report (DSR) and claims data will be sent based upon the criteria below.
DATA ANALYSIS REQUEST FOR INFORMATION (RFI) ZPIC Zone 4 – TX, OK, NM, CO http://www.qlarant.com/contracts/zpic-4 (Revised on 2018_02_28) DAF0810 CARRIER INFORMATION REQUESTS (LEIR)
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