Form Letters
This form letter is used when a claim or code is being denied stating the services rendered are denied as global to maternity/delivery.
Global Maternity
Which Dictionary is used to look up a location?
Dictionary 100
This Note Type should only be used by the Internal Credentialing Team. It is used when the provider is listed as participating in the system and the payer has the provider listed as non-par.
652 - IC USE-IC SYSTEM PAR, PAYER NON-PAR
BCBS Healthplus
60 Days from Date of Denial
CARDIOLOGY REPORTS
SELF PULL from Cardiology Imaging Viewer, Sunrise, TouchWorks (AEHR) & HIE Clinical Viewer
This form letter is used when the carrier denies a claim submission as submitted past the timely filing limit. For example, we submitted the claim 3 times to a carrier, but they
continued to state they did not have a record of the claim. By the time they had a claim on file, it was past their filing limit.
350- Late File Appeal
Which Dictionary is used to look up a Rejection code?
Dictionary 6
This Note Type is used when coding escalations need to be submitted. This note type is used, to verify if WTC and medical records support a diagnosis.
414-AR USE-COD WTC CERTIFIED DX
Healthcare Partners
60 Days from Date of Denial
EMERGENCY ROOM
SELF PULL from Sunrise – Records can be found in the following tabs: Results, Documents,
OneContent & Northwell HIE Clinical Viewer
If medical records not found – Open Note Type 375
Billing Area 1312: Available in AEHR
Billing Area 1313: Note Type 375
Peconic, Huntington & Mather's Hospital – Note Type 375
Northern Westchester & Phelps: SELF PULL from Meditech
This form letter is used when we are requesting a copy of the carrier’s EOB or are requesting appeal/claim status from the insurance carrier. It is commonly used when we are unable to contact the carrier for claim status or the carrier states they need a request in writing to send us an EOB.
FL 354 - EOB/ Status Request
Which Dictionary is used to look up a Billing area?
Dictionary 202
This Note Type is used when a Hospice or Nursing Home email has been submitted.
542- AR-HOSPICE OR NURSING HOME EMAIL SUBMISSION
Fidelis
Dual & Medicare Advantage
180 Days from Date of Denial
RADIOLOGY
SELF PULL from Carestream, TouchWorks (AEHR) & Syngo
Doctor's Office Location – DOQS & DORB: SELF PULL from Syngo
Northern Westchester & Phelps: SELF PULL from Meditech
Peconic: SELF PULL from CareStream
This form letter is used when an E&M code is denied stating another provider had billed and was already paid for these services. Our argument is that the patient was transferred to another facility being the locations are different.
Two ER Charges Different Location
Which Dictionary is used to look up a CPT code?
Dictionary 1
This Note Type is used when payment has not been received.
550- AR-PAYMENT NOT YET RECEIVED
WTC
15 months
RADIATON ONCOLOGY
SELF PULL from TouchWorks (AEHR) unless request is for:
*Radmed Treatment records
*MD Treatment Plan notes
*Physics Planning medical records
Daily Treatment medical records – SELF PULL from Aria or reach out to your Senior Rep
Note Type 375 if not found (records found in Mosaiq)
All Radiation Oncology requests (including authorization requests) should be escalated to ‘Internal
Medical Record Request’ until further notice if records cannot be found.
**For Lenox Hill and Manhasset hospital, authorizations and treatment documents are always found
in ARIA. For LIJ hospital, authorizations and treatment documents for dates of service before
12/4/2023 should be found in Mosaiq. December authorizations may overlap systems, check both
ARIA and Mosaiq. We are only using ARIA for all billing areas for dates of service after 12/4/2023**
This form letter is to be used to appeal no authorization denials when received from Affinity,Amida Care, Blue, Centerlight, Emblem (GHI/HIP, Healthcare Partners, Oxford,UHC
No Administrative Denial Appeal
Which Dictionary is used to look up a Provider?
Dictionary 3
This Note Type is used when first level appeal submission is completed for No Referral/ Not Medically Necessary.
566 - AR-AUTH APPEAL - 1ST LEVEL NO REFERRAL/MED NEC REVIEW
Hospice/Nursing
365 Days from the DOS
INPATIENT HOSPITAL BASED
SELF PULL from Sunrise – Records can be found in the following tabs: Results, Documents,
OneContent & Northwell HIE Clinical Viewer
If medical records not found – Open Note Type 375
Huntington, Mather's Hospital & Peconic: Note Type 375
Phelps & Northern Westchester: SELF PULL from Meditech