**** PLEASE TYPE FORM AND FAX TO (510) 777-2225 ****

Complete this form and FAX with supporting documents to ACBHCS Provider Relations Billing Unit within one week from receipt of payment/denial or 90 days after insurance claim submission. For questions regarding the completion of this form, please call (800) 878-1313. Forms are located at www.acbhcs.org/providers.

Date:	/ /	Completed by:
Organization:	John George Pavilion	Phone:	( ) -
Organization Fax #:	( ) -

InSyst Client Number:	RU #:

Client Name:	Sex:
LAST	FIRST	M.I.

Date of Birth:	/ /	Social Sec #:	- -

Insurance Company Name:
Medicare

SUPPORTING DOCUMENTATION

Check the box next to the type of insurance payment/denial notification document received (for this client only), and indicate the date and number of pages; attach document to this form and FAX to (510) 777-2225.

Document	RA/EOB/Denial Date	# of pages
Remittance Advice (RA)	/ /
Explanation of Benefits (EOB)	/ /
Denial Letter	/ /
Accepted Insurance/Medicare as
Payment in Full, No Balance Due	/ /
I attest that this service meets the DMH 90 day OHC billing rule.
Delegate Signature
91st Date:	/ /

Comments:

For ACBHCS Use Only	Date Received: __________________
Payment Posting Date: _______________
Entered by: _________________________ Date: ___________________

John George Pavilion

MHS Medicare/Insurance

Payment Notification Form

This document may contain protected health information only for use by the intended recipients. Any use, distribution, copying or disclosure by any persons other than the intended recipient is strictly prohibited and may be subject to civil action and/or criminal penalties. If you have received this document in error, please immediately notify ACBHCS at (800) 878-1313.

G:\Gross Claiming\InSurance Billing\JGP Medicare Insurance Payment Notification Form 06_29_12.dot

Insurance Plan Verification and Insurance Authorization Worksheet

Sphere

2012-06-29

martinjos

BHCS