FMBS Claims Status Form

Message*

Claim is in process, askClaim Paid or Partially paidClaim deniedClaim is not on file, askClaim was rejectedClaim pendedDenied as a DuplicateBundled ClaimPulling EOBS onlyReconsideration / Appeal /Document Submission Follow UpOther

Provider/Facility Name*

Call back number / Fax Number:*

Name of Person Calling on claim*

Name*

First NameLast Name

DOB*

Plan Type*

Member ID Number / Claim# for WC*

Insurance Name:*

DOS*

Billed Amount:*

Claim Number*

Insurance Rep Name:*

Ref# call:*

Adjuster Information- ASK the Rep or Look in EMA *

Rows	Response
Adjuster Name
Adjuster Phone #
Adjuster Fax#
Adjuster Email

Please upload claim copy or EOB:

Claim is in process, ask

none

What date was the claim received?

What is the claim number?

Is the claim being pended for anything?

Claim Paid or Partially paid

none

The Amount Paid

The Date Paid

The Check Number

If the check was cashed

CPT Codes*

Rows	CPT Code	Paid $	Patient Copay	Deductible	Coinsurance	Denied Reason
CPT Code 1
CPT Code 2
CPT Code 3
CPT Code 4
CPT Code 5
CPT Code 6
CPT Code 7
CPT Code 8
CPT Code 9
CPT Code 10

Would not provide line item breakdown requested EOB to be faxed to 623.374.4592

Claim denied

none

If the coverage was termed, ask for the effective and termination date of the policy*

effective datetermination date

If they say the service is not a covered benefit, ask why is it not a covered benefit*

If they state they are requesting information, ask what information they are requesting*

Medical RecordsW9Coordination of Benefits

If Other, specify below*

Where to send the requested information:*

fax numberaddress

If they state any anyother reason, write it down word for word

Claim is not on file, ask

none

If the policy is active and what is the policy effective date*

Ask for the claims address*

Ask for the fax number*

Electronic claim payor*

Timely filing limit*

Claim was rejected

none

Why it was rejected*

Pended For*

Medical RecordsW9Coordination of BenefitsOther

If Other, specify below*

Where to send the requested information:*

fax numberaddress

Denied as a Duplicate

Request status of the FIRST (original) claim Processed.

First (original claim) Details *

Rows	Details
Claim Number
Paid / Denied?
Paid / Denied Details

Bundled Claim Details

Ask rep what is the claim bundled?

Date

Billed Amount

Claim Number

CPT

Is the Provider claim being bundled to Facility? or Facility claim bundled to the Provider claim?

NoYes, Inform the rep these claims are NOT the same, The 1500 claim is for the care that provider gives and the UB04 is for the use of the facility where the care was provided. Claim is to be sent back.

Ref #:

Was the Reconsideration Received*

YesNo

YES Reconsideration Follow UP *

Rows	Response
Date Reconsideration Received
Claim Number
Reconsideration Document Number
Reconsideration Outcome (IN Process, Upheld)

NO Reconsideration Received*

Rows	Not Satisfied
What is the timely filing for the reconsideration
What address do we submit the reconsideration to?
What is the fax number for the reconsideration

Claims Status Form

Claims Status Message (Must Select One, Required)

Get the Representative Information for the Call

Claim is in process, ask

Claim Paid or Partially paid

Claim denied

Claim is not on file, ask

Claim was rejected

Claim pended for

Denied as a Duplicate

Bundled Claim

Reconsideration Follow Up

Favored Resolved

What is Required

Claim Resolution: