Get On Time Corrected Claim Form - Health New England

Filing a corrected claim online can save you time and ensure that your claim is processed promptly. This guide provides you with clear, detailed steps to effectively fill out the ON TIME CORRECTED CLAIM FORM from Health New England.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to access the ON TIME CORRECTED CLAIM FORM and open it in your preferred editing tool.
2. Identify the relevant category for your corrected claim by checking the appropriate box on the form. This could include options such as corrected member information, corrected date of service, or corrected provider information.
3. Fill in today's date and the date(s) of service related to the original claim in the designated fields.
4. Input the member's name in the specified area, ensuring that it matches the information from the original claim.
5. Provide the physician or group practice name associated with the claim. This is crucial for proper identification of the claim.
6. Enter the contact person's name and telephone number for any follow-up communication regarding the claim.
7. Complete the address section, including city, state, and zip code to ensure the form is routed correctly.
8. Input the original claim number, which is a 12-digit number found on the Explanation of Payment (EOP). This helps to reference the correct information from prior submissions.
9. In the provided space, add a brief description of the corrections made on the attached claim, detailing what specific items have been corrected.
10. Once all fields are completed, attach the necessary HCFA 1500 or UB04 claim documentation that outlines the corrections indicated on the form.
11. Save any changes made to the document. You can then download, print, or share the form as needed for submission.

Complete your ON TIME CORRECTED CLAIM FORM online for efficient processing of your claims.