Get Activ Health Claim Form - Part B (to Be Filled In By

Filling out the Activ Health Claim Form - Part B accurately is crucial for ensuring that your claim is processed smoothly. This guide provides clear, step-by-step instructions on how to complete each section of the form online.

Follow the steps to fill out the form seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete the details of the hospital section. Enter the full name of the hospital, its ID, type, treating doctor’s name, qualifications, registration number with state code, and the phone number.
3. Fill in the details of the patient admitted. Include the patient's full name, IP registration number, gender, age, date of birth, date of admission, and date of discharge.
4. In the details of ailment diagnosed section, enter the ICD-10 codes for the primary diagnosis, additional diagnoses, and any co-morbidities. Also, document the procedures performed along with their ICD-10 PCS codes.
5. If applicable, indicate if pre-authorization was obtained, providing the pre-authorization number and reason for not obtaining it if that's the case.
6. In the claim documents checklist, ensure you include all necessary submissions, such as the signed claim form, pre-authorization request, discharge summary, and other required documentation.
7. If the hospital is non-network, fill in the additional details required including the full address, phone number, and hospital registration number.
8. Read the declaration by the hospital carefully, then fill in the date, place, and obtain the signature and seal of the hospital.
9. After completing the form, save your changes. You can download, print, or share the form as needed.

Complete your Activ Health Claim Form - Part B online today for an efficient claims process.