Get Odm 06653

The Odm 06653 Medical Claim Review Request Form is essential for users looking to request a review of an unpaid claim due to specific circumstances. This guide will provide you with detailed instructions to successfully complete this form online.

Follow the steps to fill out the Odm 06653 form online.

1. Click 'Get Form' button to access the Odm 06653 Medical Claim Review Request Form and open it for editing.
2. In the Provider Information section, input the provider's name, street address, city, state, zip code, and the contact person's details.
3. For Submission Date to Medicaid, enter the date when you are submitting the form, along with the seven-digit Ohio Medicaid individual provider number and the group provider number if applicable. Include the phone number with the area code.
4. Fill in the Claim Inquiry Information by providing the recipient's name, the 12-digit billing number, and the service or discharge date.
5. In the Claims History Information section, enter the 17-digit transaction control number(s) (TCN) along with the corresponding remittance advice for the claim you are reviewing.
6. For the EOB Code Information, provide the Explanation of Benefits (EOB) codes as detailed on the department’s remittance advice related to the claim.
7. Finally, in the Explanation of Request section, articulate the reason for your request for claim review.
8. After completing all sections, review the form for accuracy, then save your changes. You can download, print, or share the completed form as needed.

Complete your documents online today for efficient processing.