Provider Payment Dispute Resolution Submission Form
Provider Contracting & Network Management
Provider Payment Dispute Resolution Submission Form
Provider Tax Identification Number:___________________ Provider Group Name & Address:________________________________________________ Provider Contact Name & Phone Number:__________________________________________ Provider E-mail Address:________________________________________________________ Date:_______________
PLEASE CHECK APPLICABLE BOX LISTED BELOW ADMINISTRATIVE DENIALS
REIMBURSEMENT DENIALS
o BNA01- NO AUTHORIZATION o NOLD1- UNTIMELY FILING
o NINEL- INELIGIBLE MEMBER o BDY01- MAX.VISITS HAVE BEEN MET FOR THIS
SERVICE
o BNC01-NOT A COVERED BENEFIT
o ALCNT- NOT REIMBURSABLE PER CONTRACT
o X0009- UNBUNDLED CHARGES
o NPRV2- NO PROVIDER CONTRACT ON FILE FOR
DATE/TYPE OF SERVICE
o NCDE1- PROCEDURE CODE MISSING OR
INVALID
o NEX05- OPERATIVE/PROCEDURE REPORT
NEEDED
o NEX49- PLACE OF SERVICE INCONSISTANT WITH
AUTHORIZATION
o OTHER- ADMINISTRATIVE DENIALS
o NINC- INCLUDED IN GLOBAL PROCEDURE OR
PRICING ARRANGEMENT
o NPC01- NO PROFESSIONAL COMPONENT
ALLOWABLE
o OTHER- REIMBURSEMENT DENIALS
Please Provide Information Listed Below Member Name:____________________________________________________________ Member Medical Record Number (MRN):________________________________________ Date of Service:____________________________________________________________ Total Billed Amount in Question:_______________________________________________ Claim Number(s):___________________________________________________________
Please Submit Appeal To: Kaiser Foundation Health Plan of the Mid-Atlantic States
2101 E. Jefferson Street, 2nd Floor East Rockville, MD 20852
ATTN: Provider Appeals Phone Number: 1 (877) 806-7470
Fax Number: (301) 388-1698
01/2012
Provider Contracting & Network Management
CHECK LIST
(Please submit Appeal with Documents listed below)
FACILITY
PROFESSIONAL
o Detailed Appeal Letter or Appeal Filing Form. (If
Appeal is submitted without Appeal Filing Form, the information listed below must be present: Reason for denial, member name & date of birth, medical record number, service dates and claim number(s)).
o Hospital Registration Sheet or Hospital Face
Sheet
o Complete Medical Records with Physician
Orders
o Copy of claim and Itemized Bill
o Detailed Appeal Letter or Appeal Filing Form. (If
Appeal is submitted without Appeal Filing Form, the information listed below must be present: Reason for denial, member name, medical record number, service dates and claim number(s)).
o Medical Records, Operative Procedure Reports,
Radiology, Pathology Reports
o Copy of Claim
o If applicable: Account Ledger and/or Screen
Print-Out. (Timely Filing Denials)
o If applicable: Medicare Summary Notice (MSN)
o If applicable: Account Ledger and/or Screen
Print-Out. (Timely Filing Denials)
o If applicable: Medicare Summary Notice (MSN) o Other
*INFORMATIONAL PURPOSES ONLY*
Kaiser Permanente Health Plan Coverage Options
HMO- Center-Based PCP
Kaiser Permanente Signature
HMO- Center or Network-Based PCP
Kaiser Permanente Select
2-Tier Point of Service (POS)
Kaiser Permanente Added Choice
3-Tier Point of Service
Kaiser Permanente Flexible Choice
EPO- Self-Funded
Kaiser Permanente Self-Funded
Medicare Cost
Kaiser Permanente Medicare Plus
Appropriate Appeal Submission Addresses:
Appeal Submission Address for Coverage Plans Listed Below:
Signature, Select, Added-Choice and Medicare Plus:
Flexible Choice:
2101 E. Jefferson Street Rockville, MD 20852
ATTN: Provider Appeals Unit
Phone Number: 1(877)806-7470
Fax Number: (301)388-1698
P.O. Box 261130 Plano, TX 75026 ATTN: Appeals
Phone Number: 1(800)392-8649
Self-Funded:
P.O. Box 30547 Salt Lake City, UT 84130-0547
ATTN: Appeals
Phone Number: 1(877)740-4117
01/2012
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- provider payment dispute resolution submission form
- lahs athletics covid testing packet
- do you need a consent form for questionnaires
- name sex age weight periodontics implants
- ocean community ymca 2021 camp registration form
- pedoman pelayanan izin edar alat kesehatan
- whitchurch stouffville chamber of commerce presents
- utilization management policy procedure standing
- financial crime and corruption
- medical group and independent practice association
Related searches
- beckett grading submission form print
- psa submission form pdf
- psa submission form print
- psa card submission form pdf
- beckett submission form pdf
- submission form template word
- content submission form template
- community health group provider dispute form
- regal medical group provider dispute form pdf
- beckett grading submission form pdf
- regal provider dispute form
- sample submission form template