Claims Review Request Form Instructions - …

1 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 .

2 Must be present for any previously submitted requests that additional information or documentation is now being provided. 5. Provider NPI #: (National Provider Identifier): Enter your 10 digit NPI #, if you have one. This field is required if the provider does not have an ID #. 6. Provider ID #: Enter your 8 digit (A or M plus 7 digits) Medicaid provider ID #. This field is required if the provider does not have an NPI #. 7. *Provider Name: Enter your provider name. 8. *Provider Address: Enter your mailing address. 9. *Member Medicaid ID # (MID): Enter the 7 digit member Medicaid ID number. This can be found in the MID column of your RA, next to the Member s name or in the Member ID field online. 10. *Member Name: Enter the member s name as it is on the RA or online. This can be found in the in the Member column of your RA or in the Member name field online.

3 11. *Dates of Service: Enter the dates of service for the claim you are requesting Review . This can be found in the FDOS & TDOS columns on your RA or in the From and Thru dates fields online. 12. *Check the applicable box for the type of claim you are requesting to be reviewed: a. COB b. Corrected claim c. Timely filing d. Recoupment e. Other 13. *Requested Actions: Simply and clearly state the information on the claim you wish to be reviewed. If you disagree with the final status or handling of a claim , please explain why and provide any information/documentation supporting your Request (such as a new or corrected claim form , EOB with remark codes, timely filing, medical records, chart notes, or reports). Example: A claim paid a service at a different rate than what is on the IDHW fee schedule. Simply state rate is incorrect and provide the rate and date of when that rate was effective.

4 14. *List Attachments: List any attachments you have provided along with this form . 15. *Signature: The person that completes this form must sign. 16. *Print Name: The person that completes this form must print their name. 17. Mail this form to: DXC Technology Box 70082 Boise, ID 83707 *Indicates required information.