Retired Connolly iHealth Technology Collateral Discussion Request Form

DRF10302014 Recovery Audit Contractor for CMS DISCUSSION REQUEST FORM Please Note: If during the Discussion Period Connolly is notified by the MAC that the Provider has filed an appeal, Connolly is obligated to immediately discontinue the Discussion Period for that related claim(s). For more information on Discussion Requests and/or the RAC process, please see INSTRUCTIONS ∼ Launch this form and complete it electronically. Connolly ∼ One form must be submitted per claim. Spring Mill Corporate Center; Suite 6125 ∼ Print completed form, and sign by authorized representative. 555 E. North Lane ∼ This form should be the first page of each submission. Conshohocken, PA 19428 ∼ Include any accompanying documentation you believe is FAX: 203-529-2995 necessary to support the request. ∼ Please Note: Due to the inconsistent quality and reliability of fax transmission, we do not recommend single fax transmissions over 50 pages, and we do recommend a single transmission for each individual claim. OUR RESPONSE We will respond to an appropriately-submitted Discussion Request within 30 days of receipt. Our response will be sent via fax to the number you provide below. If our fax transmission is unsuccessful after 3 attempts, our response will be mailed to the same address as the Review Results Letter you received from Connolly. To update your contact information, you can click on ‘Provider Login’ at YOUR CONTACT INFORMATION FOR THIS REQUEST FAX Number for Connolly Response _ Printed Name, Title/Designation Phone Number Extension Signature MM/DD/YYYY Date YOUR REQUEST Please note that only one Discussion Request is available per claim, so please be as specific as possible when describing the reason(s) for your request. If there is no reason provided, or is a generic statement (e.g. “the services were medically necessary”) our review will be based solely on the information you previously provided. MM/DD/YYYY ICN (Claim Number) actual length may vary Date of Service Complete form electronically and print – please do not hand write. Please tab to next page if you need additional space. DRF11052014