Get Dismissal Form

The Dismissal Form is an essential document for users seeking a review of Medicare Managed Care dismissal decisions. This guide will walk you through filling out the form online, ensuring that you complete each section accurately to facilitate your request.

Follow the steps to effectively complete the Dismissal Form online.

1. Press the ‘Get Form’ button to access the Dismissal Form and open it for editing.
2. Begin with the Maximus case number; input the relevant case number assigned to you.
3. Indicate the case priority by selecting one of the following options: ‘Expedited,’ ‘Standard Service (Pre-service),’ or ‘Standard Claim (payment).’
4. Provide the date(s) of service related to your appeal in the designated field.
5. Select the reason for the plan’s dismissal from the provided options, which include: ‘Untimely Filing of Appeal,’ ‘Waiver of Liability missing,’ ‘Not an Authorized Rep,’ ‘Not a Valid Rep of Estate,’ or ‘Other.’
6. Fill out the enrollee data section. Enter the enrollee name, HIC number, street address, phone number, city, state, and zip code.
7. Specify if the enrollee needs the Dismissal Determination Notice in a language other than English by selecting ‘Yes’ or ‘No.’ If ‘Yes,’ indicate the preferred language.
8. Complete the requestor data section by checking the appropriate box to identify who is requesting the dismissal review (options include Enrollee, Enrollee’s Treating Physician, Enrollee’s Estate, Non-Contract Provider, Representative, or Surrogate acting in accordance with State Law).
9. Enter the name of the requestor, their phone number, street address, city, state, and zip code.
10. Provide the Medicare Health Plan (MHP) data, including the address for dismissal review correspondence, the CMS Contract number, and the plan name.
11. List the MHP contact person for the dismissal review along with their name, fax number, email, and alternate contact person or supervisor information.
12. In the Dismissal Case File Narrative section, summarize the dismissal case, provide a chronology of events, outline the MHP dismissal rationale, and offer justification citations.
13. Indicate whether specific documents are included in the file by selecting 'Yes' or 'No' for each listed document.
14. Once all sections are completed, save your changes. You can then download, print, or share the completed form as needed.

Begin filling out your Dismissal Form online today to ensure your dismissal request is properly submitted.