Healthcare Outlier Payment Form
Submit a request for outlier payment review and processing. Please complete all required fields to ensure accurate and timely handling of your request.
Provider Organization Name
*
Provider Contact Name
*
First Name
Last Name
Provider Contact Email
*
example@example.com
Provider Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Encounter ID or MRN
*
Date of Service
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Claim Number
*
Service Type
*
Please Select
Inpatient
Outpatient
Emergency
Surgical
Other
Billed Amount (USD)
*
Reason for Outlier Payment Review
*
Submit Request
Should be Empty: