Form Dobicappcar - Health Care Provider Application To Appeal A Claims Determination Page 3

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Submit to: United Concordia
PO Box 69420
Attn: Andrew LaCour
Harrisburg, PA 17106-9420
Provider Name:
Contact Number:
Member Name :
DOS:
You may provide additional information in an attachment to explain why you are disputing Our
handling of the claim. You must be specific about billing codes and reason for dispute.
The following should be submitted with your appeal (copies only):
The relevant claim form
The relevant Explanation(s) of Benefits or Remittance Advice
A statement specifying the line items that you are appealing
Copies of any overpayment requests or A/R notice
Information We previously requested that you have not yet submitted, if available
Itemization of the provider contract provisions you believe We are not complying with, including a copy of the
pertinent section of your contract
Pertinent correspondence between you and Us on this matter
A description of pertinent communications between you and Us on this matter that were not in writing
Relevant sections of the National Correct Coding Initiative (NCCI) or other coding support you relied upon IF the
dispute concerns the disposition of billing codes
Other documents you may believe support your position in this dispute (this may include medical records)
Attachments:
Yes
No
Signature:
Date:
/
/
Important to Note
In order to ensure your Internal Payment Appeal is eligible to meet processing requirements for the
External Binding Arbitration Program
The Internal Appeal Form must be sent to the address posted on Our website;
The Internal Appeal Form must have a complete signature (first and last name);
The Internal Appeal Form Must be Dated;
There is a signed and dated Consent to Representation in Appeals of UM
Determinations and Authorization for release of Medical records in UM Appeals and
Independent Arbitration of Claims Form
DOBICAPPCAR 10/10
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