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  • Provider Adjustment Request Form - Peach State Health Plan

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Provider Adjustment Request Form Please utilize this form to request a review of claim payment received that does not correspond with the payment expected. Matters addressed via this form will be.

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Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date when the services were provided.

Appeal Process A member must send an Appeal to Peach State Health Plan within 60 calendar days from the date of the Notice of Adverse Benefit Determination.

Appeals must be submitted within 365 calendar days of date of service or date of discharge.

Claims Appeals If you are not satisfied with result of your Claim Adjustment request, you may submit a written appeal within 30 days of the decision. You will receive acknowledgement of your written appeal within 10 days of receipt.

Timely Filing Requirements: All claims must be received by the plan within six (6) months from the date the service was provided in order to be considered for payment.

Failure to file a claim within six months after a service is rendered and/or failure to obtain a required prior approval or precertification will result in a denial of that claim.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232