Provider Appeal Request - My Preferred Provider

1 Provider Appeal Request INSTRUCTIONS. 1. Complete all of the sections below, and sign where form and supporting documentation to: indicated. 2. Along with the claim, submit COPIES of: Grievance & Appeals Department CMS-1500 or UB04 Preferred Care Partners Any medical records or documentation that supports P. O. Box 56-6420. the Appeal Miami, Florida 33256-6420. Pertinent correspondence between you and us on this matter Or fax TOLL FREE to: 1-866-261-1474. Relevant sections of the National Correct Coding Questions? We're here to help! Call the Appeals Initiative (CCI) or other coding support you relied Department toll free at 1-888-291-5721, or TTY 711. upon IF the dispute concerns the disposition of billing for the hearing impaired. We are open Monday codes through Friday from 9:00am to 5:00pm. Provider Information Provider NAME GROUP. ADDRESS. CONTACT NAME TELEPHONE.

2 Patient Information MEMBER NAME MEMBER ID DATE OF BIRTH. ADDRESS. Appeal Information I wish to submit an Appeal to Preferred Care Partners regarding the denial of the following: Claim Authorization CLAIM OR AUTHORIZATION # DATE OF SERVICE DENIAL REASON. TOTAL CHARGES (CLAIM Appeal ONLY) NAME OF PHYSICIAN PROVIDING SERVICE (AUTHORIZATION. Appeal ONLY). Reason for reconsideration: SIGNATURE DATE. Doc #: PCP00056_20140918.