Request for Claim Review Form
Massachusetts Administrative Simplification Collaborative–Request for Claim Review V1.01 Request for Claim Review Form Today’s Date (MM/DD/YY): Health Plan Name:
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www.hcasma.org• Original claim or service lines within a claim that denied as a duplicate. Filing Limit • A first time claim submission that denied for, or is expected to deny for untimely filing. • When the member did not identify himself or herself as a payer’s member (misidentified member). • A re-review of a claim denied for insufficient filing ...
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