Get Gammis

Filling out the Gammis Interim Provider Payment Request Form is essential for providers experiencing delays in their payments. This guide offers a clear, step-by-step process to assist users in completing the form accurately and efficiently.

Follow the steps to successfully complete the Gammis form.

1. Click ‘Get Form’ button to retrieve the Interim Provider Payment Request Form and access it in your browser.
2. Begin by filling out Section 1, which includes selecting the transaction type. Specify whether you are requesting an interim payment or canceling a prior request. Complete the required fields for payee identification, including your Federal Tax Identification Number and Medicaid Payee Provider Number.
3. Proceed to Section 2 and enter the details of the payee, such as name, address, and the total percent of annual revenue from Medicaid/PeachCare for Kids Programs. Ensure to provide the list of individuals who attended Provider Training, if applicable.
4. In Section 3, focus on claim and payment information. Indicate the type of media for claim submission and the specific week the claim information corresponds to. Also, provide the number of claims not processed, the billed amount, total payment received, and the interim payment amount you are requesting.
5. Describe any billing or processing issues causing payment delays in Section 3, which is necessary for the processing of your request. Include details of rendering providers if you wish, as this can assist with the allocation of received payments.
6. Fill out Section 4 with contact information for the person preparing the form. This includes their name, email address, and phone number.
7. In Section 5, provide the fax number and email address for submitting the form. Ensure that your form is submitted via fax or email, as indicated.
8. Finally, complete the attestation in Section 6 by signing and dating the form. Confirm the accuracy of the submitted details and understand the recoupment responsibilities.
9. After thoroughly reviewing each section, you can save any changes made. Then download, print, or share the completed form as required.

Complete your Interim Provider Payment Request Form online today to ensure timely processing of your payment.