Get Department Of Health Services Division Of Health Care Access And Accountability F-13047a (08/15)

Filling out the DEPARTMENT OF HEALTH SERVICES Division Of Health Care Access And Accountability F-13047A (08/15) form online is a straightforward process. This guide will provide step-by-step instructions to help you accurately complete the form and ensure your appeal is processed efficiently.

Follow the steps to complete your timely filing appeals request.

1. Click the ‘Get Form’ button to access the necessary form and open it for editing.
2. Begin by filling in the required fields, including your name, address, and member identification number. Ensure that all information is accurate and matches what is provided in ForwardHealth’s records.
3. Indicate the specific claims that are subject to the timely filing appeals request. Check the appropriate statements that relate to your situation, such as claim denials or changes in level of care.
4. If applicable, provide the claim number or payer claim control number, along with details about the original processing, including the remittance advice and check issue date.
5. Explain briefly the nature of the problem and any previous efforts you made to resolve the claims. This section should be clear and concise to help reviewers understand your situation.
6. Sign and date the form in the designated sections. Ensure that your signature is clear and that you provide the correct date.
7. If supporting documentation is required, attach the completed Explanation of Medical Benefits form, F-01234, along with any relevant records. Make sure all attachments are organized.
8. Once the form is completed, you can save your changes, download a copy for your records, and print it if necessary. Be sure to submit the form along with the corresponding claims to ForwardHealth.

Start completing your DEPARTMENT OF HEALTH SERVICES form online today to ensure timely processing of your appeals request.