Claim Review Request Form
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1THIS FORM MUST BE SIGNED AND MAILED TO:
Date: _____________________
*
Molina Provider Correspondence
Po box 70082
Boise, ID 83707
DO NOT FAX THIS FORM
Claim Review Request Form
Check the applicable box (only select one):
*
Claim Review Request (Molina Review)
Medicaid Review (DHW Review) Please refer to the “Medicaid Review of Claim Determination” section in
the MMIS Provider Handbook, General Billing Instructions
Complete the following:
Claim ID to review:
*
(Only indicate one claim number per form)
Case #(If applicable):
Provider NPI#:
(This field is required if the provider does not have an ID#)
Provider ID#:
(This field is required if the provider does not have an NPI#)
Provider Name:
*
Provider Address:
*
City:
State:
Zip:
*
Member Medicaid ID#:
*
Member Name:
Dates of service:
*
*Indicates a required field.
Check the applicable box:
*
COB
Corrected Claim
Timely filing
Recoupment
HMS
Other
Requested actions:
*
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
List attachments:
*
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Signature: ______________________________ Print Name: ________________________________
*
Last Updated: 4/19/2017
FRM001
Page 1
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Parent category: Business