Physician Name*:
Physician Tax ID*:
Email*:
Contact:
Phone Number:
Payer*:
Product:
Claim ID Number:
Patient name:
Patient subscriber number:
Date of service:
Please provide a brief description of claim/issue and expected results:
You MUST attach the following for your request to be accepted:
- Copy of the EOB
- Copy of the claim
- Appeal reconsideration paperwork (An appeal must be submitted BEFORE you submit a request to NTENT)Claim (HCFA) (downloadable):
Explanation of Benefits (downloadable):
Reconsideration/Appeal Request and Denials (downloadable):