Empire State Medical, Scientific and Educational ...
Empire State Medical, Scientific and Educational Foundation, Inc.
865 Merrick Avenue, Suite 160N * Westbury, NY 11590 * Phone: 516-437-8134 * Fax: 516-282-7113
1 APPLICATION FOR DISPUTE RESOLUTION/EXTERNAL APPEAL REVIEW
**Complete All Sections Legibly**
Patient Name:
Parent/Guardian (as applicable):
Account # (if applicable) Medical Record #:
Date(s) of Service:
Requestor’s Name:
(All correspondence/questions will be directed to person listed as “Requestor”.)
Title/Department:
Facility/Company:
Mailing Address:
City State Zip
Phone: ( ) Fax: ( )
Requestor’s Email address:
Health Care Provider (if different than Requestor):
Mailing Address:
2 City State Zip
Contact Person: Phone: ( )
Contact Email address:
Payor/Insurer/(*If UHC-Line of Business):
Contact Person: Phone: ( )
Mailing Address:
City State Zip
Contact Email address:
Insured’s name (if different from patient):
Insured’s ID #: Insured’s Claim/Reference #:
*If insurer is United HealthCare, indicate line of business: Community, Commercial, Oxford, Medicare.
Is a check for the review fee attached (made payable to ESMSEF, Inc.): [ ] Yes [ ] No
OR
Deduct the review fee from your prepaid DRA account? (as available): [ ] Yes [ ] No
OR
Charge review fee to appropriate account? (as available): [ ] Yes [ ] No
PLEASE INDICATE THE ISSUE IN DISPUTE:
[ ] Level of Care Denial [ ] Length of Stay Denial [ ] Readmission
[ ] DRG discrepancy – Please indicate which grouper various you are using:______________
[ ] Other (describe in detail below)
DESCRIBE IN DETAIL THE ISSUE IN DISPUTE. FOR DRG DISPUTES, INDICATE CLEARLY THE CODES/DRG BILLED BY THE PROVIDER. FOR UR ISSUES, INDICATE CLEARLY THE LEVEL OF CARE BEING PROPOSED, # OF DAYS/DATES BEING DENIED. (Attach additional pages if necessary):
Signature of Requestor Date
Return completed application, a copy of the complete medical record, internal appeal correspondence including Insurer denial letters, and the non-refundable review fee ($450) when applicable to:
Empire State Medical, Scientific and Educational Foundation, Inc.
Attn: DRA Department
865 Merrick Avenue, Suite 160N
Westbury, NY 11590
Phone: 516-437-8134
Fax: 516-282-7113
**Upon receipt of this completed application, complete medical record and review fee, the Foundation will notify all relevant parties (provider, payor) that a dispute has been requested. The Foundation will allow these parties twenty (20) days to submit comments relevant to the dispute.
**This application may be reproduced for future use**
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