provider corrected claim form - pacificsource

PacificSource Community Health Plans is an HMO/PPO plan with a Medicare contract. Y0021_PVDR880_Plan Approved 09202011 Corrected Claim Form A corrected claim is a claim that has been processed and the claim needs to be corrected. Please type or print in ink. Patient Last Name First M.I. Member # Claim # Provider Name REASON FOR REVIEW / RECONSIDERATION Please include supporting documentation, such as chart notes or a letter of medical necessity. Chart notes must be included for corrected diagnosis, corrected date of service, corrected patient information, corrected procedure codes, and corrected provider information. Corrected diagnosis Corrected patient information Corrected provider information Corrected date of service Corrected procedure code (CPT or CM) Precertification/Preauthorization Corrected charges (increased or reduced) Bundled Claim Corrected modifier (addition or change) Please note: Modifier changes require chart notes as well as an explanation. For example: Modifier 59— why do you feel this was a distinct and separately identifiable service? Or Modifier 22—why do you feel that additional reimbursement is warranted? Other: ____________________________________________________________________________ Please attach a copy of the corrected CMS 1500 or UB reflecting the changes noted above, and list any clarifications or special instructions in the space below: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Please return this form to: PacificSource Medicare Claims Department Research Analyst PO Box 7068 Springfield, OR 97475 Fax: (541) 225-3634

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Page 1: Provider Corrected Claim Form - PacificSource

PacificSource Community Health Plans is an HMO/PPO plan with a Medicare contract.

Y0021_PVDR880_Plan Approved 09202011

Corrected Claim Form A corrected claim is a claim that has been processed and the claim needs to be corrected.

Please type or print in ink.

Patient Last Name First M.I. Member #

Claim # Provider Name

REASON FOR REVIEW / RECONSIDERATION

Please include supporting documentation, such as chart notes or a letter of medical necessity. Chart notes must be included for corrected diagnosis, corrected date of service, corrected patient information, corrected procedure codes, and corrected provider information.

Corrected diagnosis

Corrected patient information

Corrected provider information

Corrected date of service

Corrected procedure code (CPT or CM)

Precertification/Preauthorization

Corrected charges (increased or reduced)

Bundled Claim

Corrected modifier (addition or change)

Please note: Modifier changes require chart notes as well as an explanation. For example: Modifier 59—why do you feel this was a distinct and separately identifiable service? Or Modifier 22—why do you feel that additional reimbursement is warranted?

Other: ____________________________________________________________________________

Please attach a copy of the corrected CMS 1500 or UB reflecting the changes noted above, and list any clarifications or special instructions in the space below: ____________________________________________________________________________________

____________________________________________________________________________________

Please return this form to: PacificSource Medicare

Claims Department Research Analyst PO Box 7068

Springfield, OR 97475 Fax: (541) 225-3634

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