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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