First Appeal – First Med Claims Appeals Pro

1. CLAIM INFORMATION

Appeal Category

APPEAL TYPE NAME:

Payor Name:

Payor Address

Payor Type

Department:

Original Payer:

Date of Authorization

Amount Internal Authorization

Authorization Number

Capitated Hospital

Capitation

Health Plan

IPA/Medical Group

MSO/Third-party organization

Amount Billed

Amount Denied

Base

Authorized Services Rendered

Mileage

Bariatric Transport

Bariatric Transport Fee

Response and Treatment, Dry Run

Wait Time

Paid Amount

Underpaid Amount

CPT Code

Modifiers

Origin/Destination

Patient Name:

First

Last

Date of Birth:

Member ID:

Internal PDR#:

Claim Number:

Date(s) of Service:

Status

File Upload

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