Get Ohp 3085 Request For Claim Or Payment Authorization Review - Apps State Or

The OHP 3085 form is essential for users seeking a review of specific coverage decisions made by the Division, coordinated care organizations, or prepaid health plans. This guide provides clear and straightforward instructions to help users complete the form accurately and efficiently online.

Follow the steps to successfully complete your OHP 3085 request form.

1. Click the 'Get Form' button to access the OHP 3085 document and open it in your preferred editing tool.
2. Identify and complete the 'Requesting Provider' section, which includes your name, National Provider Identifier, and contact information. Ensure accuracy in these fields.
3. In the 'Service Information' section, enter the Client ID, the client's date of birth in MM/DD/YYYY format, and their name in the order of last, first, and middle initial. Additionally, specify the dates of service.
4. In the 'Decision Information' section, clarify what the decision relates to by selecting one of the provided options and entering the relevant Internal Control Number or prior authorization number, as applicable. Include the decision date.
5. In the 'Reasons for Review' section, mark all applicable reasons that justify your request for review. Be sure to include any specifics that relate to the case.
6. Compile and attach all necessary supporting documentation. This should include a copy of the decision notice, the original claim or service authorization request, proof of client eligibility, and any relevant medical records or data that support your reasons.
7. Once you have filled out all sections thoroughly and attached the required documents, review the entire form for accuracy and completeness.
8. Finally, save your changes, download the completed form, or print a copy for your records before submitting it to the Provider Services address specified on the form.

Complete your OHP 3085 request form online today to ensure your coverage review is processed efficiently.