Get 01.05 Provider Resubmission Form - Pacificare.com - Pacificare.com
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How to fill out the 01.05 Provider Resubmission Form - Pacificare.com online
Filling out the 01.05 Provider Resubmission Form is essential for successfully appealing provider disputes and correcting claim reimbursements. This guide provides clear, step-by-step instructions to help you navigate the form easily and effectively.
Follow the steps to complete the 01.05 Provider Resubmission Form accurately.
- Click ‘Get Form’ button to access the 01.05 Provider Resubmission Form. This allows you to download and open the form in your preferred editor.
- Fill in the date at the top of the form. This should be the date when you are completing the appeal or resubmission.
- In the 'Submitted By (Name)' section, enter your full name as the person submitting the form.
- Provide the 'Provider Name/Group' in the next field, ensuring it matches with the name registered with Pacificare.
- Enter the 'Provider Address.' This should include the street address, city, state, and ZIP code.
- Add the 'Provider Phone Number' to ensure that Pacificare can contact you if needed.
- Fill in the 'Provider Tax ID' to identify your tax records accurately.
- Indicate the 'Volume of Claims in Question' based on the number of claims you are disputing.
- Select appropriate options under 'Provider Appeals.' Mark the relevant reasons for your appeal, such as 'ClaimCheck Denial' or 'Timely Filing.'
- In the 'Corrected Claim Reason for Resubmission' section, provide specific reasons for submitting the corrected claim by checking the applicable boxes.
- Use the 'Additional Comments' section to elaborate on your appeal or to attach any necessary documentation.
- After completing the form, review all entered information for accuracy. Save changes, download the filled form, and prepare to submit it.
- Finally, you can print or share the filled-out form as required. Include all documentation, such as Explanation of Benefits.
Complete your documentation online today to ensure timely processing of your resubmission.
PacificSource is a health insurance provider that offers a range of insurance products, including individual and family plans, Medicare Advantage, and Medicaid. They focus on providing comprehensive coverage tailored to meet the needs of their members. You can find detailed information on their offerings by visiting Pacificare. If you need specific forms, such as the 01.05 Provider Resubmission Form - Pacificare - Pacificare, they are readily accessible on their website.
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