Appeals Form (3) - NYNMonline.com

New York Network Management, LLC Appeals Form Provider Name: Practice: 0HPEHU ODVW QDPH ¿UVW QDPH Member ID #: Insurance Plan: Claim #: DOS: Detailed ...

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New York Network Management, LLC Appeals Form Provider Name: Practice: 0HPEHUODVWQDPH¿UVWQDPH Member ID #: Insurance Plan: Claim #: DOS: Detailed reason for denial:

Please attach a copy of the claim (HCFA or print out from Claimschannel360) and any supporting documentation (Check the appropriate squares below): Authorization numbers/cover letters Proof of timely submission Copies of primary EOB Medical notes Member eligibility proof (screenshots or other) Member ID card copy Copy of invoice(s) Patient consent forms Referrals Corrected claim forms Other

As of December 5th 2011 ALL APPEALS and CORRECTED CLAIMS MUST GO TO THE NEW PO BOX: NYNM IPA Appeals/COB PO BOX 640 LAKE KATRINE NY 12449

NEW YORK NETWORK MANAGEMENT IPA www.nynmonline.com 888-511-5208