Pip Post-Service Appeal Form

ADVERTISEMENT

NEW JERSEY PIP POST-SERVICE APPEAL FORM
1. DATE APPEAL SUBMITTED
2. RECEIPT DATE OF ADVERSE DECISION
TYPE OR PRINT LEGIBLY AND KEEP WITHIN THE LINES OF THE
SPACE PROVIDED
CLAIM INFORMATION
3. INSURANCE COMPANY
4. CLAIM #
5. DATE OF LOSS
PATIENT INFORMATION
6. LAST NAME
7. FIRST NAME
8. MIDDLE INITIAL
9. DATE OF BIRTH
10. ADDRESS (No. Street)
11. CITY
12. STATE
13. ZIP
PROVIDER/FACILITY INFORMATION
14. LAST NAME
15. FIRST NAME
16. FACILITY-OFFICE NAME
18. TAX ID #
19. NPI #
17. SPECIALTY
20. ADDRESS (No. Street)
21. CITY
22. STATE
23. ZIP
24. TELEPHONE # (Include Area Code)
25. FAX # (Include Area Code)
26. EMAIL ADDRESS
27. PROVIDER AVAILABILITY DAYS OF WEEK:
28. PROVIDER AVAILABILITY TIME OF DAY:
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
FROM
TO
DOCUMENTS INCLUDED
29. CHECK THOSE APPLICABLE BELOW (Include Proof of Receipt if Applicable)
*ORIGINAL BILL (HCFA/UB)
*EXPLANATION OF BENEFIT/PAYMENT
*APPEAL RATIONALE NARRATIVE
APTP DECISION/RESPONSE
INDEPENDENT MEDICAL EXAM REPORT
PEER REVIEW REPORT
AUDIT REPORT
NETWORK TERMINATION DOCUMENT
PPO CONTRACT
OTHER SUPPORTING DOCUMENTS (Describe):
POST-SERVICE APPEAL ISSUES
30. EOB ID
31. TOTAL BILL REIMBURSEMENT
32. EXPECTED BILL REIMBURSEMENT
33. **BILL LEVEL APPEAL CODE(S) 1-10
34. DATE(S) OF SERVICE
35. CPT, HCPCS, NDC
36. LINE LEVEL REIMBURSE
37. LINE LEVEL EXPECTED
38. **LINE LEVEL APPEAL
FROM
TO
AMOUNT
REIMBURSE AMOUNT
CODE(S) A-S
MM
DD
YY
MM
DD
YY
* Indicates minimum documents required that must be included with the submission of this form with ADDITIONAL/NEW supporting records only
** Indicates sections that should be completed using the letter(s)/number(s) that correspond to the reason codes on the back of this form
FRAUD PREVENTION-NEW JERSEY WARNING
ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL
PENALTIES.
PROVIDER STATEMENT
I HAVE PERSONALLY COMPLETED OR REVIEWED THIS FORM. THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
39. SIGNATURE OF PROVIDER
40. DATE
Page 1 of 2
PIP Post-Service Appeal Form Version 1.2 (2/2017)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2