CA HMO Fax Cover Sheet – General Ambulance Transport Request for Authorization
December 29, 2024 6:15 pmREQUEST FOR AUTHORIZATION At this time, we are requesting authorization to provide transportation services... View more
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CA HMO Fax Cover Sheet – General Ambulance Transport Appeal
December 29, 2024 3:02 pmREQUEST FOR RECONSIDERATION We believe you have failed to comply for the following reasons:... View more
CA HMO Appeal – Ambulance Transport Contract No Authorization Improper Notice
December 17, 2024 7:11 amURGENT- IMPERATIVE ACTION Dear Director of : This office has been asked to file a formal complaint with the Department... View more
CA HMO Appeal – General Ambulance Transport No Contract Underpayment
December 17, 2024 7:01 amURGENT- IMPERATIVE ACTION Dear Director of : This office has been asked to file a formal complaint with the Department... View more
CA HMO Affidavit – General Ambulance Transport No Contract Underpayment
December 17, 2024 6:48 amAFFIDAVIT OF COMPLIANCE Expected Reimbursement for Non-Contracted Ambulance Transport Claims Incorporated by Reference in 28 US Code § 1746 Patient/Multiple... View more
CA HMO Affidavit – Untimely Filing with Exceptional Circumstance
November 30, 2021 10:17 pmAFFIDAVIT OF COMPLIANCE Untimely Filing with Exceptional Circumstance Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: ... View more
NV HMO Script – Notice Requirements for Adverse Determinations
October 18, 2021 1:32 amASK YOURSELF: Who denied the claim? What is the professional’s license number with the State Medical Board? Were they a... View more
MO HMO Appeal – Poststabilization Timeframe
October 15, 2021 9:57 amIMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Missouri Department... View more
GA HMO Script – Retroactive Denial for Authorized Care
October 15, 2021 9:50 amASK YOURSELF: Was the coverage terminated? Did we verify eligibility? If so, what date and time? Did the plan make... View more
GA HMO Script – No Authorization for ER Services and Care
October 15, 2021 9:47 amASK YOURSELF: What was the patient’s presenting symptoms or chief complaint in the emergency room? Did the plan pay for... View more