Hawaii State Department of Health
[pic] |Department of Health
Adult Mental Health Division
PROVIDER CLAIM
AND PAYMENT INQUIRY
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|Agency Name: |Date: |
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|Contact Name: |Contact Phone Number: |
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| |Fax number: |
|Claim Type (check one) |
|A. CMS 1500 Claim form B. UB-92 Claim form |
|C. Electronic claim file, date provider submitted to AMHD: |
|Electronic claim file name, (example, “prod.837.25.20080711.txt”): |
| |
|Claim Information Please complete the following information. Additional paper may be used for more claims. |
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|Incomplete information will be returned as unprocessed. |
|Consumer |Date of Birth |Date Claim was Submitted |Date of Service|Procedure Code |AMHD Authorization Number |
|Name | |to AMHD | | | |
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|Please Fax Completed Form along with a Secure Fax Cover Page to: |
|Attn: AMHD, Provider Relations |
|Fax: (808) 586-4745 |
AMHD Use Only
Date PR forwarded to AMHD Fiscal: _______________ Date PR received from AMHD Fiscal: ________________
AMHD Fiscal Response:
Claim received? No, Provider needs to resubmit claim
Yes, payment is/will be reflected in a Remittance Advice Report (“RA”)
Yes, claim was denied and is/will be reflected in a Remittance Advice Report (“RA”)
Yes, but claim process was suspended and returned to provider (Report to Provider, “RTP”)
Provider not in AMHD System; request PR to begin Provider Application Process when applicable
Date PR responded to Provider: _________________ Telephone Email Letter Face-To-Face
Comments:
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