Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to access the Online Exceptional Claims Form. This will allow you to open the document for filling out.
2. Enter the provider name, contact information, and provider number in the designated fields at the top of the form.
3. In the main section of the form, indicate your request for an exception to the timely filing limit by checking the appropriate criteria that applies to your claim. You will find sections for claims that are more than 12 months old and those that are less than 12 months old.
4. If your claim is more than 12 months old, review Section I. Check the corresponding box that aligns with the reason for your exceptional claim, and attach any required documentation.
5. For claims less than 12 months old, proceed to Section II. Check the relevant reason and ensure that you include any necessary documentation, such as the Medicare Explanation of Benefits (EOMB).
6. Use Section III to specify any other reasons for your request that do not fall under the previous categories. Provide a clear explanation in the space provided.
7. Finally, sign and date the form to complete the process. Make sure to review all entries for accuracy.
8. Once completed, you can save your changes, download the form for your records, or print it directly for mailing.

Begin filling out the Online Exceptional Claims Form today to ensure timely processing of your exceptional claims.