Medical Claim Review Request Form
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2OHIO DEPARTMENT OF JOB AND FAMILY SERVICES
PROVIDER NETWORK MANAGEMENT SECTION
MEDICAL CLAIM REVIEW REQUEST FORM
INSTRUCTIONS TO COMPLETE THIS FORM ARE ON THE REVERSE SIDE
.
1. PROVIDER INFORMATION
2. SUBMISSION DATE OF THIS FORM
___/___/___
Provider Name
Individual Provider#__ __ __ __ __ __ __
_______________________________________
Address_________________________________
City
Group Provider#__ __ __ __ __ __ __
(When appropriate)
State
Zip
Contact Person
_________________________
Telephone # (
)-
3. CLAIM INQUIRY INFORMATION
4. CLAIM HISTORY INFORMATION
Recipient Name
Transaction Control Numbers
Billing #(12digits)
TCN_______________________________________
Service Date
TCN_______________________________________
or
TCN_______________________________________
Discharge Date
Please note: All transaction control #s are 17 digits
5. Please enter all applicable Medicaid E.O.B. denial codes, which apply to the attached
claim.
EOB _____ EOB_____ EOB_____ EOB_____
(Please include all necessary documentation, e.g. remittance advices, Medicare and/or Insurance EOBs).
Internal Use Only
6.Explanation of request:
_____________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Date of Receipt Stamp
9
ODJFS USE ONLY
Claim not approved for processing, please see the attached letter.
Reviewer ID
Each claim requires a separate JFS 06653 Medical Claim Review Request Form
Please call our Interactive Voice Response Unit (IVR) at 1-800-686-1516 for claim status verification.
JFS 06653 (Rev.07/2003)
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Parent category: Medical