Provider Payment Appeal - InTotal Health Providers

0 downloads 133 Views 60KB Size Report
Toll Free: 1.855.323.5588. Fax Number: 877.685.5729. Provider Name: _. Provider NPI Number: _. Insured's Medicaid ID #:.
Provider Payment Appeal Request Form st

1 Level Payment Appeal – provider dissatisfaction with a claim payment/denial for services that is not due to preauthorization medical necessity denial nd

2

Level Payment Appeal - provider dissatisfaction with the first level payment appeal decision

INTotal Health, Attn: IRU PO Box 5448 Richmond, VA 23220 Toll Free: 1.855.323.5588 Fax Number: 877.685.5729

Insured's Medicaid ID #: Patient Name:

Provider Name:

_

Provider NPI Number:

_

_ _

Date Sent:

Contact Person: Authorization#:

Name: Telephone: Mailing Address:

Dates of Service: __________

Claim Number: Charge Amt: Place of Treatment: Select from list

Fax Number:

Please describe appeal and requested action:

____