Form Letters
Dictionaries
Note Types
Timely Filing 1st Level Appeal
Medical Records
100

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

100

Which Dictionary is used to look up a location?

Dictionary 100

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

100

BCBS Healthplus

60 Days from Date of Denial

100

CARDIOLOGY REPORTS

SELF PULL from Cardiology Imaging Viewer, Sunrise, TouchWorks (AEHR) & HIE Clinical Viewer

200

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

200

Which Dictionary is used to look up a Rejection code?

Dictionary 6

200

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

200

Healthcare Partners

60 Days from Date of Denial

200

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

300

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

300

Which Dictionary is used to look up a Billing area?

Dictionary 202

300

This Note Type is used when a Hospice or Nursing Home email has been submitted.

542- AR-HOSPICE OR NURSING HOME EMAIL SUBMISSION

300

Fidelis
Dual & Medicare Advantage

180 Days from Date of Denial

300

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

400

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

400

Which Dictionary is used to look up a CPT code?

Dictionary 1

400

This Note Type is used when payment has not been received.

550- AR-PAYMENT NOT YET RECEIVED

400

WTC

15 months

400

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**

500

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

500

Which Dictionary is used to look up a Provider?

Dictionary 3

500

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

500

Hospice/Nursing

365 Days from the DOS

500

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