Navigating the complexities of healthcare billing and insurance procedures is a challenging endeavor, particularly for healthcare providers managing the nuances of claim submissions and appeals. Central to this process for those involved with Parkland Community Health Plan, is the Parkland College Claim Appeal Form. This critical document serves as a bridge for providers who seek reconsideration of payment decisions made by the insurance entity. The form requires detailed information, including provider and member identifiers like names, National Provider Identifier (NPI) numbers, member ID numbers, and dates of birth. It also asks for specific claim information such as the claim number, the date of service, and the amount billed. Crucially, the form provides space for a detailed narrative of the appeal, urging providers to articulate the specifics of their request clearly and to attach any additional documents that could support their case. Its design facilitates a structured yet flexible approach to presenting an appeal, underlining the importance of clarity and detail in the pursuit of a favorable resolution. This form, to be sent to a specified mailing address, is where the formal process begins, backed by the understanding that each piece of information could play a pivotal role in the appeal's outcome. The person requesting the adjustment must also include their contact details, underscoring the interactive nature of this process, which hinges on effective communication between Parkland Community Health Plan and healthcare providers.
| Question | Answer |
|---|---|
| Form Name | Parkland College Claim Appeal Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | parkland claims, plan provider claims appeal form, parkland community plan form, parkland health plan form |
PROVIDER CLAIMS APPEAL FORM
Complete this form and return to Parkland Community Health Plan for processing your appeal.
Provider Name: _____________________ |
Provider NPI: ____________________ |
Member Name: _____________________ |
Member ID Number: ____________________ |
Member DOB: _____________________ |
Claim Number: ____________________ |
Date of Service: _____________________ |
Amount Billed: ____________________ |
Please describe in detail, the nature of your appeal and include the date of service. Please print or write legibly. Attach additional documents if necessary.
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Attach all documentation and return to:
Parkland Community Health Plan
P.O. BOX 569150
DALLAS, TX 75356‐9150
Person Requesting Adjustment:__________________
Phone Number:__________________
Date:____________________