Claims inquiry form

Claims inquiry form

Provider Name*

Provider #*

Billing Agency requesting on behalf of Provider

(If applicable)

Submitter information*

Please include submitter name, job title, phone, and email address.

Member Name*

Member ID #*

Claim #*

Date(s) of Service *

Service Code*

Please specify reason for Claim Inquiry *

Please include any supporting documents eg. Remittance Advices, Medicare Vouchers etc.

If multiple claims are included on your request, please include a spreadsheet with all claim numbers.

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