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MEDICARE MANAGED CARE DISMISSAL CASE FILE DATA FORM MAXIMUS CASE NUMBER CASE PRIORITY Expedited Standard Service Pre-service Standard Claim payment 4-a. DATE S OF SERVICE IN QUESTION 3. PLAN S DISMISSAL REASON Untimely Filing of Appeal Waiver of Liability missing Not an Authorized Rep Not a Valid Rep of Estate Other ENROLLEE DATA Enrollee Name HIC Street Address Enrollee Phone City State Does the Enrollee require the Dismissal Determination Notice in a language other than English No Zip Yes specify language 4-b. REQUESTOR DATA i*e* person/entity requesting the dismissal review check one Enrollee Enrollee s Treating Physician Enrollee s Estate Non-Contract Provider Representative Name of Requestor Phone Street Surrogate acting in accordance with State Law MEDICARE HEALTH PLAN MHP DATA Address for Dismissal Review Correspondence CMS Contract REQUIRED Plan Name MHP CONTACT PERSON FOR THIS DISMISSAL REVIEW Contact Person Name Fax Number Email Alternate Contact Person or Supervisor Name DISMISSAL CASE FILE NARRATIVE 2. DISMISSAL CHRONOLOGY This should be a brief overview of the timeline of events in this case. Please refer to claim numbers for dates of service as appropriate 3. MHP DISMISSAL RATIONALE 4. JUSTIFICATION i*e* citations to rules upon which plan dismissed 5. Please indicate if the following documents are included in the file a* b. c* d. Correspondence of attempts to get representative documentation/WOL if applicable Notice of Dismissal Appeal Letter or phone records if expedited request was made Documentation regarding the plan s assessment of good cause if applicable. PLAN S DISMISSAL REASON Untimely Filing of Appeal Waiver of Liability missing Not an Authorized Rep Not a Valid Rep of Estate Other ENROLLEE DATA Enrollee Name HIC Street Address Enrollee Phone City State Does the Enrollee require the Dismissal Determination Notice in a language other than English No Zip Yes specify language 4-b. REQUESTOR DATA i*e* person/entity requesting the dismissal review check one Enrollee Enrollee s Treating Physician Enrollee s Estate Non-Contract Provider Representative Name of Requestor Phone Street Surrogate acting in accordance with State Law MEDICARE HEALTH PLAN MHP DATA Address for Dismissal Review Correspondence CMS Contract REQUIRED Plan Name MHP CONTACT PERSON FOR THIS DISMISSAL REVIEW Contact Person Name Fax Number Email Alternate Contact Person or Supervisor Name DISMISSAL CASE FILE NARRATIVE 2. REQUESTOR DATA i*e* person/entity requesting the dismissal review check one Enrollee Enrollee s Treating Physician Enrollee s Estate Non-Contract Provider Representative Name of Requestor Phone Street Surrogate acting in accordance with State Law MEDICARE HEALTH PLAN MHP DATA Address for Dismissal Review Correspondence CMS Contract REQUIRED Plan Name MHP CONTACT PERSON FOR THIS DISMISSAL REVIEW Contact Person Name Fax Number Email Alternate Contact Person or Supervisor Name DISMISSAL CASE FILE NARRATIVE 2. DISMISSAL CHRONOLOGY This should be a brief overview of the timeline of events in this case. Please refer to claim numbers for dates of service as appropriate 3.

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