Epo/ppo Corrected Professional Paper Claim Form - Emblem Health

EPO/PPO CORRECTED

PROFESSIONAL PAPER CLAIM FORM

INSTRUCTIONS

Effective September 1, 2013, this form must be completed if you are making a correction to a previously submitted and adjudicated

EmblemHealth EPO/PPO paper claim. All paper claims without this form will be processed as a new claim and denied as a duplicate.

1. Provide the original claim number* ___________________________________________________________________

2. Check the box that corresponds to the claim information you need to correct and provide the correction.

3. When necessary, give a brief description of the change.

4. Mail this completed form and the corrected CMS Professional 1500 claim form to the PO Box that corresponds to your correction.

Please mail this form and the corrected claim to: PO Box 2815, New York, NY 10116

o Correct Provider

Tax ID:

Physician Name:

o Correct Procedure Code

Original Code:

Correct Code:

o Correct Member

Original Member Name:

Original Member ID:

Correct Member Name:

Correct Member ID:

o Corrected Provider Bill Charge:

$

o Corrected Unit(s):

With Procedure Code(s):

o Corrected Dates of Service:

_____/_____/______, _____/_____/______, _____/_____/______

o Corrected Place of Service:

o Other:

Please mail this form and corrected claim to: PO Box 3000, New York, NY 10116

o Correct Modifier:

With Procedure Code:

o Correct Diagnosis Code (Original Code):

Correct Code:

o Coordination of Benefits: (EOB and claim attached to form.)

*You can look up the claim number by signing in to and using the claims look-up feature.

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services

Company, LLC provides administrative services to the EmblemHealth companies.

EMB_PR_FRM_14401_CORRECTCLAIMSFORM 8/13