Please refer to the Molina Provider Manual for timeframes and more information. Appeals related to Authorizations should be submitted using the Authorization Reconsideration Form. Corrected Claims Please send corrected claims as a normal claim submission electronically or via the . Provider Portal. Multiple Claims
Claim Reconsideration Request Form Date: __/__/____ Please submit the request by visiting our Provider Portal, or fax to (800) 499-3406. Attach all required supporting documentation. Incomplete forms will not be processed. Forms will be returned to the submitter. Please refer to the Molina Provider Manual for timeframes and more information. Appeals related to Authorizations should be submitted using the Authorization Reconsideration Form. Corrected Claims Please send corrected claims as a normal claim submission electronically or via the Provider Portal. Multiple Claims If multiple claims with the same denial require an appeal, attach an Excel sheet. Note: Multiple claims must be from the same rendering provider and for same claim denial reason. Contact Person Provider/Group Name Provider NPI Provider Phone # Provider Information Contact Phone # Provider Tax ID/Medicare ID Provider Fax # Member Name Member Date of Birth Member Information Member Account # Molina Member ID Line of Business Claim Information Molina Original Claim ID Original Claim Amount Billed Dates of Service Claim Information Medicaid Marketplace Medicare MMP Single Claim Multiple Claims LTSS Denial Reason (Mark all applicable) Duplicate Service Processed under incorrect Provider/Tax ID Overpayment/Underpayment Exceeded timely filing limit Missing/Incorrect NDC Coordination of Benefits (COB) Processed under incorrect member National Correct Coding Initiative (NCCI) Edit Eligibility Other (Please explain) Additional Information: MHO-0779 0119Microsoft Word 2013