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The new form is also available at hcasma.org. This form was created by the Massachusetts Health Care Administrative Simplification Collaborative in an effort to simplify the claim appeal review process for providers. Network Notification Date May 30 2012 Number 133 TO All BMC HealthNet Plan Providers FROM BMC HealthNet Plan SUBJECT Universal Provider Request for Claim Review Form PRODUCT MassHealth Commonwealth Care Commercial Summary In an effort to streamline the claims review process for providers BMC HealthNet Plan has begun accepting the Universal Provider Request for Claims Review Form. Effective August 1 2012 this form will replace BMC HealthNet Plan s Provider Administrative Appeal Form located in Section 15. 1 of our Provider Manual* You can access the Provider Manual and this new form on our website at bmchp*org. To ensure efficient processing please complete all form fields. Note that if BMC HealthNet Plan needs to return a submitted form for any reason the information provided in the Contact Name and Contact Address sections will be used* Please note that the new form does not change BMC HealthNet Plan s existing appeals policies or submission address further described in Section 10. 5 of the Provider Manual* However all references in Provider Manual Section 10. 5 to the Provider Administrative Appeal form are deleted and substituted with the Universal Provider Request for Claims Review Form* Questions If you have any questions about this Network Notification please contact your provider relations representative or call the provider line at 1-888-566-0008. All BMC HealthNet Plan Network Notifications are available online at bmchp*org. Two Copley Place Suite 600 Boston MA 02116 WWW*BMCHP. To ensure efficient processing please complete all form fields. Note that if BMC HealthNet Plan needs to return a submitted form for any reason the information provided in the Contact Name and Contact Address sections will be used* Please note that the new form does not change BMC HealthNet Plan s existing appeals policies or submission address further described in Section 10. 5 of the Provider Manual* However all references in Provider Manual Section 10. 5 to the Provider Administrative Appeal form are deleted and substituted with the Universal Provider Request for Claims Review Form* Questions If you have any questions about this Network Notification please contact your provider relations representative or call the provider line at 1-888-566-0008. 5 of the Provider Manual* However all references in Provider Manual Section 10. 5 to the Provider Administrative Appeal form are deleted and substituted with the Universal Provider Request for Claims Review Form* Questions If you have any questions about this Network Notification please contact your provider relations representative or call the provider line at 1-888-566-0008. All BMC HealthNet Plan Network Notifications are available online at bmchp*org. Two Copley Place Suite 600 Boston MA 02116 WWW*BMCHP.

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