Denial Letter Information Form

Facility Profile
Your Name*
First Last
Email*
Phone
Facility*
Denial Letter Information
Audit/Denial Type
- Government Audit/Denial
- Commercial Audit/Denial
Issue Category
- Medical Necessity
- Coding
- Diagnosis Validation
PCN#*
Patient Name*
First Last
Member #*
Notice Date*
# Days to Submit Appeal (from Notice Date)*
Service From:*
Service To:*
Payer Name*
Phone #*
Fax#*
Standard Appeal Mailing Address*
Audit/Denial Rationale*