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Claim to Include but not limited to:

Professional, Institutional & Dental Claims, Primary / Secondary/ Tertiary Claims with EOB/EOMB, Corrected Claims, Resubmission Claims, Member Claims, Roster Claims and Vaccination Claims.

Attachment for Appeals & Grievances to Include but not limited to:

Appeals and Grievances, Medical Records, Clinical Records, Additional Information, Copy of EOB/EOMB, Critical Claim Information, Consent Form, Trauma Report, Claim Payment Dispute, Claim Payment Dispute-Proof of Timely Filing/Member Cost Share/Claims Editing (CCI/LCD/NCD).

Other Attachment Include but not limited to:

Copy of ID Card, Copy of Medicare Card, Date of Injury, Invoice, Itemized Bill, Pre-Certification/Authorization Information, Referral, W9, Cost Containment-Overpayment/Refund/COB & Hospice, Provider Information Change Form, DME Review.

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