Rework Form

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					                                       Claims Rework Request
                     North Texas    San Antonio        Austin        Houston        Tulsa     Oklahoma City

Please submit all claim rework requests by completing one form per claim and submitting to the address listed below.
Please note that all claim rework requests must be submitted within 60 days of receipt of explanation of payment (EOP)
or denial letter. If the rework request is not received within specified deadline, the provider forfeits the opportunity for
the claim to be reviewed. All rework requests must be submitted with all the applicable documentation listed below.
                                              Provider Information
  Date:                                    Product:          Secure Horizons                Commercial

  Provider Name:                                                Tax Identification #:

  Office Contact Name:                                          Phone:                         Fax:
  Member Name:                                                  Member ID#:
  Date of Service:                                              Amount of Claim:

                                     Reason for Claim Rework Request
  Check     Type of Claim Issue                           Supporting Documentation Must be Submitted
            Claim not paid per contract                   Copy of Rate page and signature page from contract
            Claim Edit                                    Copy of Medical Records to support additional payment
            Clinical Issue                                Copy of Medical Records
            Length of Stay -all days not paid             Copy of Medical Records
            Miscellaneous Code/Add'l Description          Itemized Statement or Invoice
  Check     Type of Claim Issue                           Additional Information Needed
            Paid to wrong provider               Correct provider is: __________________________
            Incorrect member                     Correct member is:___________________________
            Other Insurance                      Policy Name and ID#: ________________________
            Copay Incorrect                      Should be: _________________________________
            Claim Denied no Auth                 Circle one: No Auth needed or Copy of Auth is attached
            Check Lost/Voided Need to reissue    Check number is:____________________________
            Benefits assigned incorrectly
            Incomplete payment, Check original HCFA/UB for other Procedures listed
            Paid # of units incorrectly
  Please provide a description of problem/issue:

               Please submit claim rework requests form and supporting documentation to:
                                     Attn: Claim Rework Resolution
                                            P. O. Box 29127
                                        San Antonio, Texas 78229
                                                                                                      Last update: 12/11/02

Description: Rework Form document sample