The following information must be completed on the Appeal/Payment
Review Action Request form.
DATE OF SERVICE QUARTER:
Enter the State’s quarter and year the service was rendered: 2QTR13, 3QTR13 etc.
Enter the date the form is being completed.
PAYMENT DATE VALIDATED?
This will be always be "No" for appealing providers, as
this form is also used by the health plan for appeals to the State.
IF PROVIDER APPEALS, HAS PLAN REVIEW INTERNALLY?
The applicable responses are "Yes", "No", "N/A-Plan Based Appeal". Since MDCH wishes
the Health Plans to review all appeals initially, HealthPlus of Michigan will complete
this item, upon review.
ISSUE TYPE (check only one):
Check the box that best describes the outstanding issue, either an accounting issue
or volume/data missing issue. Provide a summary of issue to enable sufficient review.
Fax the completed Appeal/ Payment Review Action Request to:
Provider Network Management, Attn: Appeal/ Payment Review Action Request: 810-230-2081
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