INSTRUCTIONS/DETAILS: DATE OF DISCOVERY: The date documents were found that deems claims/invoices unsubstantiated. DATE OF SERVICE/INVOICE: Date the service was provided/invoice was billed NAME OF INDIVIDUAL: that received service SERVICE BILLED: list the service that was provided REASON/EXPLANATION: explain why the service/invoice is unsubstantiated and how it was found. OPPORTUNITY TO REBILL: Provide explanation on why it is/is not able to be rebilled ERROR/NOT BILLABLE: we shouldn’t have billed it, service was not provided LOST REVENUE: it should be billed but for some reason Medicaid wouldn’t accept it, or we provided services that were not accepted CORRECTIVE ACTION TAKEN: Explain/list any measures that have been put in place to ensure further incidents will not happen **ALL NAMES AND TITLES MUST BE PRINTED AND THEN SIGNATURES BELOW. NAMES AND TITLES MUST BE LEGIBLE IN ORDER TO PROCESS THE DOCUMENT** REQUESTED BY (PRINT NAME AND TITLE): SIGNATURE: DATE: APPROVED BY (PRINT NAME AND TITLE): SIGNATURE: DATE: CORPORATE COMPLIANCE (PRINT NAME AND TITLE): SIGNATURE: DATE:
INSTRUCTIONS/DETAILS: DATE OF DISCOVERY: The date documents were found that deems claims/invoices unsubstantiated. DATE OF SERVICE/INVOICE: Date the service was provided/invoice was billed NAME OF INDIVIDUAL: that received service SERVICE BILLED: list the service that was provided REASON/EXPLANATION: explain why the service/invoice is unsubstantiated and how it was found. OPPORTUNITY TO REBILL: Provide explanation on why it is/is not able to be rebilled ERROR/NOT BILLABLE: we shouldn’t have billed it, service was not provided LOST REVENUE: it should be billed but for some reason Medicaid wouldn’t accept it, or we provided services that were not accepted CORRECTIVE ACTION TAKEN: Explain/list any measures that have been put in place to ensure further incidents will not happen **ALL NAMES AND TITLES MUST BE PRINTED AND THEN SIGNATURES BELOW. NAMES AND TITLES MUST BE LEGIBLE IN ORDER TO PROCESS THE DOCUMENT** REQUESTED BY (PRINT NAME AND TITLE): SIGNATURE: DATE: APPROVED BY (PRINT NAME AND TITLE): SIGNATURE: DATE: CORPORATE COMPLIANCE (PRINT NAME AND TITLE): SIGNATURE: DATE:
VOIDWRITEOFFFORMfull.docx