INET Provider Portal Support/Appeal Status
*Disclaimer: HCFA-1500 OR UB-04 ORIGINAL OR CORRECTED CLAIM FORMS ARE NOT ACCEPTED THROUGH THIS PORTAL, PLEASE SEE NEW CLAIM FAQ ON INTEGRANET HOME PAGE
Name
*
First Name
Last Name
Email
*
example@example.com
Please choose your issue below
*
Please Select
Appeal Status
Provider Portal Support
Member ID
*
Date of Service
*
-
Month
-
Day
Year
Date
Claim Number
Billed Charge
*
Reason for Request
Assigned Case Number or Previous Ticket #
User ID
*
User Name
*
First Name
Last Name
ERA Request
*
NPI
Tax ID
Clearing House
Submit
Should be Empty: