Claim Inquiry Fax Form

September 11, 2014

Be proactive and reduce wait time for getting claims paid by using this form to check claim status.

To download this form, click here: Claim Inquiry Tax Form.doc


CLAIM INQUIRY FAX FORM

ATTN: PROVIDER ASSISTANCE DEPARTMENT

ATTN: CLAIMS DEPARTMENT

THIS IS A CLAIM STATUS REQUEST. PLEASE COMPLETE THE BOX BELOW AND FAX BACK TO OUR OFFICE AS SOON AS POSSIBLE. YOUR PROMPT ATTENTION TO THIS MATTER WOULD BE GREATLY APPRECIATED.

 

Physician Name: __________________________________________

Federal Identification Number: _______________________________

Phone Number: ______________________________

Fax Number: ________________________________

Name of Person Submitting Inquiry: __________________________

 

  • Check here if claim was electronically filed
  • HCFA 1500 attached to this form

 

PAYER RESPONSE

 

 ☐ CLAIM NOT ON FILE (REFILE TO CLAIMS DEPT. FOR PROCESSING)

 ☐ CLAIM RECEIVABLE BUT NOT YET PAID

 ☐ CLAIM SENT TO MEDICAL REVIEW

 ☐ MORE INFORMATION IS NEEDED TO PROCESS CLAIM (See Comments Below)

Comments:

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To download this form, click here: Claim Inquiry Tax Form

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