1 Level Payment Appeal – provider dissatisfaction with a claim payment/denial for services that is not due to preauthorization medical necessity denial nd
2
Level Payment Appeal - provider dissatisfaction with the first level payment appeal decision
INTotal Health, Attn: IRU PO Box 5448 Richmond, VA 23220 Toll Free: 1.855.323.5588 Fax Number: 877.685.5729
Insured's Medicaid ID #: Patient Name:
Provider Name:
_
Provider NPI Number:
_
_ _
Date Sent:
Contact Person: Authorization#:
Name: Telephone: Mailing Address:
Dates of Service: __________
Claim Number: Charge Amt: Place of Treatment: Select from list
