Form Odm 06653 (Formerly Jfs 06653) - Medical Claim Review Request
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1Reset Form
Ohio Department of Medicaid
MEDICAL CLAIM REVIEW REQUEST
2. SUBMISSION DATE OF THIS FORM
1. PROVIDER INFORMATION
___/___/___
Provider Name _________________________________
Individual Provider # ___ ___ ___ ___ ___ ___ ___
Address ___________________________________________
City _______________________________________________
Group Provider # __ __ __ __ __ __ __
(When appropriate)
State _________________
Zip __________________
Telephone # (
)_____________________________
Contact Person ______________________________________
3. CLAIM INQUIRY INFORMATION
4. CLAIM HISTORY INFORMATION
Transaction Control Numbers
Recipient Name _____________________________________
TCN _______________________________________________
Billing # (12 digits) ___________________________________
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
MEDICAID USE ONLY
Claim not approved for processing, please see the attached letter.
Reviewer ID
Each claim requires a separate ODM 06653 Medical Claim Review Request Form
Please call our Interactive Voice Response Unit (IVR) at 1-800-686-1516 for claim status verification.
ODM 06653 (7/2014)
Formerly JFS 06653 (Rev. 5/2010)
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Parent category: Medical