PEN Billing Claims Questions Form

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CS EYE PEN BILLING CLAIMS RESEARCH

General Information

Date/Time*

Clinic Name (and Location if more than one office)*

Name of person submitting this form*

First Name

Last Name

Phone Number of person to contact at your office if needed*

Fax Number of person to contact at your office if needed*

PEN ID #*

Response preference:

I would like a call back once research is completed I would like a fax back once research is completed No return call needed - call me only if you have questions

Claims to Research

You will have the option below to submit up to 10 claims for research per request. Once you complete a section, click "add another" to complete another claim section.

Do you have a general or claim specific question?

General Claim Specific

Please describe your non-claim specific question below in detail so we can research:*

Patient Name*

First Name

Last Name

Patient DOB*

Date(s) of service for above patient:*

Action needed:*

Check status Correct Claim Submit to Secondary Cancel Claim Submission

Other:

Question or issue description:*

Add another? (check yes or submit form below if no)

Yes

Faxing supporting document for this claim (see instructions below)*

Yes No

Patient Name*

First Name

Last Name

Patient DOB*

Date(s) of service for above patient:*

Action needed:*

Check status Correct Claim Submit to Secondary Cancel Claim Submission

Other:

Question or issue description:*

Have another claim to research? (check yes or submit form below if no)

Yes

Faxing supporting document for this claim (see instructions below)*

Yes No

Patient Name*

First Name

Last Name

Patient DOB*

Date(s) of service for above patient:*

Action needed:*

Check status Correct Claim Submit to Secondary Cancel Claim Submission

Other:

Question or issue description:*

Add another? (check yes or submit form below if no)

Yes

Faxing supporting document for this claim (see instructions below)*

Yes No

Patient Name*

First Name

Last Name

Patient DOB*

Date(s) of service for above patient:*

Action needed:*

Check status Correct Claim Submit to Secondary Cancel Claim Submission

Other:

Question or issue description:*

Add another? (check yes or submit form below if no)

Yes

Faxing supporting document for this claim (see instructions below)*

Yes No

Patient Name*

First Name

Last Name

Patient DOB*

Date(s) of service for above patient:*

Action needed:*

Check status Correct Claim Submit to Secondary Cancel Claim Submission

Other:

Question or issue description:*

Add another? (check yes or submit form below if no)

Yes

Faxing supporting document for this claim (see instructions below)*

Yes No

Patient Name*

First Name

Last Name

Patient DOB*

Date(s) of service for above patient:*

Action needed:*

Check status Correct Claim Submit to Secondary Cancel Claim Submission

Other:

Question or issue description:*

Add another? (check yes or submit form below if no)

Yes

Faxing supporting document for this claim (see instructions below)*

Yes No

Patient Name*

First Name

Last Name

Patient DOB*

Date(s) of service for above patient:*

Action needed:*

Check status Correct Claim Submit to Secondary Cancel Claim Submission

Other:

Question or issue description:*

Add another? (check yes or submit form below if no)

Yes

Faxing supporting document for this claim (see instructions below)*

Yes No

Patient Name*

First Name

Last Name

Patient DOB*

Date(s) of service for above patient:*

Action needed:*

Check status Correct Claim Submit to Secondary Cancel Claim Submission

Other:

Question or issue description:*

Add another? (check yes or submit form below if no)

Yes

Faxing supporting document for this claim (see instructions below)*

Yes No

Patient Name*

First Name

Last Name

Patient DOB*

Date(s) of service for above patient:*

Action needed:*

Check status Correct Claim Submit to Secondary Cancel Claim Submission

Other:

Question or issue description:*

Add another? (check yes or submit form below if no)

Yes

Faxing supporting document for this claim (see instructions below)*

Yes No

Patient Name*

First Name

Last Name

Patient DOB*

Date(s) of service for above patient:*

Action needed:*

Check status Correct Claim Submit to Secondary Cancel Claim Submission

Other:

Question or issue description:*

Add another? (check yes or submit form below if no)

Yes

Faxing supporting document for this claim (see instructions below)*

Yes No

Due to data encryption, you may not upload any supporting documents directly to this request.

To send a supporting document, please fax to 888-898-2102 and make sure to write the submission number that appears on the next page.

DO NOT SUBMIT ANY OTHER DOCUMENTS WITH THESE SUPPORTING DOCUMENTS