OR HMO Fax Cover Sheet – Notification of Disagreement of Care
December 30, 2024 11:01 amNOTIFICATION OF DISAGREEMENT OF CARE On , you notified our facility that further post-stabilization... View more
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CA HMO Fax Cover Sheet – Request for Authorization of Post-stabilization Services
December 30, 2024 12:42 amREQUEST FOR AUTHORIZATION TO PROVIDE POST-STABILIZATION SERVICES : Federal regulations require that you (1)... View more
CA HMO Fax Cover Sheet – Notification of Disagreement of Care
December 30, 2024 12:37 amNOTIFICATION OF DISAGREEMENT OF CARE On , you notified our facility that further post-stabilization... View more
WA HMO Fax Cover Sheet – Competent Reviewer Request
December 30, 2024 12:32 amCOMPETENT REVIEWER REQUEST : Washington law requires that there is a right to request... View more
WA HMO Fax Cover Sheet – Request for Authorization of Post-stabilization Services
December 30, 2024 12:26 amREQUEST FOR AUTHORIZATION TO PROVIDE POST-STABILIZATION SERVICES : Federal regulations require that you (1)... View more
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
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