MHO Claim Reconsideration Form - Molina Healthcare
Claim Reconsideration Request Form
Date: __/__/____
? Please submit the request by voiusritpinregfeorurredPrmoevtihdoedr,Pvoisritainl,gotrhefaPxrtoov(i8d0e0r)P4o9r9ta-3l,4b0y6.visiting
hAtttpacsh://awllwrweq.auviraeidlitsyu.pcpoomrt/imngoldinocauhmeaelnthtactaiorne., or fax to:
PInlceMMoaseymedCpiracleerafetieedrO,ftohMorimotahrsMekweMetdipolillcainacnoreaet,-PCbaMrneoldepavdrMiiidocmceyaerCidsMasRPreaedlena.OuncFahoPolioornfmosMstrsiCtewdidlmaielieclmrafbria:ade(mt5Priee6lotas2unn)arnnP4Rde9od9smet-t0ooCq6rlteu1ah0ieiemnssf:uot(br8mFm0a0iott)itroe4rnm9..9-3406
Date: __/__/____
MCPloeuralrsteiepc????slteeePPAIAAIPAAnndCnlltpdlceeptptceMCCtplaoaappoaaaccessomlcseeomoieehaasemaharlpltipirllsrsamrlnsseaeRuleelreaclflbrrtfsleeeteeeermMeclrrlleraedfoaatfiqtoetqottvtoeocueerduedtrmlddtihimitrahrcrhtyeeistteeoasmeoo:drdrwMAew(eMsAAs8sqiuuiDoalu8uuuollptsllp8tte-hlinphhiSpnna)sonooootooaN3rantrrrrtbi9tiPioPzbtizPzybi6narreanarePmo-tgvtotgi1poviipoivaodo5srsidrnlidonion1todotsccescs7iCceclnerusesarsulgshmMhsahimMsomsioooeemeuaeuuduandnlsnl:ln.rdt.ududtau(FaPFbatb5babtiolmroei6oleeroofr2nmifsomnsvsso).uruu.sisrsb4dibbtowtmi9wemmimn9mriiiiil-teletPtlet0ltftelfebero6ebdraddec1reamtut0muurraseeoessleitsitin,nusnuniogargrgcanrnnanttdteehflhdhalddeyeemxmttAoAAoootooruruutrtevhthe(tth8iheiehaino0noossfrt0fruruohio)iibbzrezzrm4ammmaaP9ttatiiiari9itttooottiot-nieoenn3vorrn.4inR.RR.d0.eeee6crcc.oooPnnnosssiriiddtdaeeerlrr.aaatttiiiooonnnFFFooorrrmmm...
If multiple claims with the same denial require an appeal, attach an Excel sheet.
CPCPNllooeeorraatrrsseeeee:ccsMstteeeennuddddltCCiccplloolaaerriirrmmececlcssatteiemdd sccllmaaiiummstss
be aass
from the aa nnoorrmmaall
same rendering provider and for ccllaaiimm ssuubbmmiissssiioonn eelleeccttrroonniiccaallllyy
same oorr vviiaa
claim denial reason. tthhee PPrroovviiddeerr PPoorrttaall..
This
includes
attachments
for
CMOuBltioprleitCemlaiizmeds statements. MIf mulutilptilpeleCclalaiimmss with the same
denial
require
an
appePalr, oavttaidcheranIEnxfcoerlmshaeetit.on
INfoCmtoeun:lttMiapculetltPciplealreismocslnawimitshmthuestsabme efrdoemnitahleresaqmuierereandaepripnegalp, raotvtaicdheraannEdxfcoeCrlsosanhmteaect.ctlPaihmonden#ial reason.
NoPtreo:vMiduelrti/pGleroculapimNsamuest be from the same rendering provider and for same claim denial reason.
Provider NPI Provider Phone # Contact Person
Provider InforPmroavtidioenr Tax ID/Medicare ID
Provider Fax # Contact Phone #
Provider/Group Name Provider NPI Member Name Provider Phone # Member Date of Birth
Member Information
Provider Tax ID/Medicare ID Member Account # Provider Fax # Molina Member ID
MLienme boefrBNuasimneess Member Date of Birth Claim Information
MCemlaibmerIInnfoforrmmaatitoionn
Medicaid
MarketplaMceember AccoMunetd#icare
MMP
Single Claim
Molina MembMeruIlDtiple Claims
LTSS
Molina Original Claim ID Original Claim Amount Billed LDianteeos foBf Suesirnveicsse Claim Information
Claim Information
Medicaid
Marketplace
Single Claim
Medicare
MMP
Multiple Claims
LTSS
Molina Original Claim ID
Denial Reason (Mark all applicable)
OriDgiunpallicCaltaeimSerAvmicoeunt Billed DatPersoocfeSsseerdviucneder incorrect Provider/Tax ID
Coordination of Benefits (COB) Processed under incorrect member
Overpayment/Underpayment
Denial Reason (MarkNaalltiaopnpallicCabolrer)ect Coding Initiative (NCCI) Edit
Exceeded timely filing limit
Eligibility
DMuipssliicnagt/eInSceorrvrieccet NDC
COotohredrin(PalteioanseoefxBpelanienf)its (COB)
Processed under incorrect Provider/Tax ID
Processed under incorrect member
AdOdviteiorpnaayl mInefnort/mUantdioernp: ayment Exceeded timely filing limit
National Correct Coding Initiative (NCCI) Edit Eligibility
Missing/Incorrect NDC
Other (Please explain)
Additional Information: Additional Information:
28328FRMMDOHEN 220418
MMHHOO--00777799 00412129
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