Internal Claim FROM TO Procedure Units of DETAIL LINE FOR INTERNAL USE ONLY Control Detail Dates of Dates of Code Service Billed Amount Determination Decision Number, ICN Line # Service Service Modifier Modifier Modifier Modifier Date: Signature of the Provider Representative : Email address for Provider Representative: ___________________________________ If you need more space, please use a separate form and indicate in your email request that additional pages were needed.
Internal Control Number, ICN Claim Detail Line # FROM Dates of Service TO Dates of Service Procedure Code Modifier Modifier Modifier Modifier Units of Service DETAIL LINE Billed Amount FOR INTERNAL USE ONLY Determination Decision Signature of the Provider Representative : Date: Email address for Provider Representative: ___________________________________ If you need more space, please use a separate form and indicate in your email request that additional pages were needed.
180+Day+Timely+Filing+Exception+Request+Form.docx