Transcription of CLAIM INFORMATION PATIENT INFORMATION …
1 MMDDYYMMDDYY35. SIGNATURE OF PROVIDER36. DATEPage 1 of 1 PIP Pre-Service Appeal Form Version (2/2017)* Indicates minimum documents required that must be included with the submission of this form with ADDITIONAL/NEW supporting records onlyFRAUD PREVENTION-NEW JERSEY WARNINGANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL STATEMENTI HAVE PERSONALLY COMPLETED OR REVIEWED THIS FORM.
2 THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND REVIEW REPORT27. PROVIDER AVAILABILITY DAYS OF WEEK:TODIAGNOSTIC REPORT(S)*APPEAL RATIONALE NARRATIVEMONDAYTUESDAYDOCUMENTS INCLUDED28. PROVIDER AVAILABILITY TIME OF DAY:FROMWEDNESDAYTHURSDAYFRIDAY20. ADDRESS (No. Street)21. CITY22. STATE23. ZIP24. TELEPHONE # (Include Area Code)25. FAX # (Include Area Code)26. EMAIL ADDRESS11. CITYPROVIDER/FACILITY INFORMATION17. SPECIALTY18. TAX ID #19. NPI # PATIENT INFORMATION9. DATE OF BIRTH7. FIRST NAME6. LAST NAME13. ZIP12. STATE10. ADDRESS (No. Street)YES INDICATE WITH XTYPE OR PRINT LEGIBLY AND KEEP WITHIN THE LINES OF THE SPACE PROVIDEDNEW JERSEY PIP PRE-SERVICE APPEAL FORM1.
3 DATE APPEAL SUBMITTED2. RECEIPT DATE OF ADVERSE DECISIONCLAIM INFORMATION5. DATE OF LOSS8. MIDDLE INITIAL14. LAST NAME15. FIRST NAME16. FACILITY-OFFICE NAME3. INSURANCE COMPANY33. ADMINISTRATIVE DISPUTEYES INDICATE WITH X4. CLAIM #31. CPT, HCPCS, NDC30. DATE(S) OF REQUESTFROMTOPRE-SERVICE APPEAL ISSUES 29. CHECK THOSE APPLICABLE BELOW (Include Proof of Receipt if Applicable)*ORIGINAL APTP FORMINDEPENDENT MEDICAL EXAM REPORTOTHER SUPPORTING DOCUMENTS (Describe):*APTP DECISION/RESPONSE DOCUMENT34. MEDICAL NECESSITY DISPUTEYES INDICATE WITH X32. RESPONSE NOT RECEIVED WITHIN 3 BUSINESS DAYS
