Get Alternative Care Claim Form For Providers - Providence Health ... - Healthplans Providence
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How to use or fill out the Alternative Care Claim Form For Providers - Providence Health online
Filling out the Alternative Care Claim Form for providers requires attention to detail and accurate information. This guide will walk you through the process step-by-step to ensure your claim for alternative care services is submitted correctly.
Follow the steps to complete the form accurately.
- Click ‘Get Form’ button to obtain the claim form and open it for editing. This allows you to begin the process of filling out the required information.
- Provide patient and subscriber information. Enter the patient's full name, birth date, and sex. Include the member ID number, address, and the subscriber's details, including their name, group number, and address.
- Detail the services received. In this section, list each date of service individually. For each entry, include the procedure code, any applicable modifiers, the number of units, and the charges associated with each service.
- Complete the rendering provider's information. Enter the full name, address, ZIP code, and phone number of the provider who rendered the services.
- Provide the facility's information where the services were rendered. Fill in the facility name and address, as well as the tax identification number and NPI number for verification.
- Attach the required documentation. Include an itemized bill with a proof of purchase or payment receipt alongside the completed form.
- Submit the claim. Send the form and the attached documents to Providence Health Plans at the specified address. Ensure your submission is within the allowed time frames for claim processing.
- Finally, save your changes, download, print, or share the completed form as needed for your records.
Complete your claims quickly and accurately by following these steps to fill out the Alternative Care Claim Form online.
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To fill out the Alternative Care Claim Form for Providers - Providence Health ... - Healthplans Providence, start by entering your personal details, including your name, address, and insurance policy number. Ensure you provide specific information about the treatment or services received, including the dates and costs. You should double-check for accuracy to avoid delays in processing your claim. Using clear and concise information will help streamline the process.
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