CDAE Claims Audit Documentation Checklist Form
Complete the CDAE Claims Audit Documentation Checklist Form to ensure all required documentation is collected and reviewed.
Claim Reference Number
*
Date of Audit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Claimant Name
*
Supporting Documentation Uploaded
*
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of
Checklist: Medical Records Attached
*
Yes
Checklist: Explanation of Benefits (EOB) Included
*
Yes
Checklist: Provider Billing Submitted
*
Yes
Checklist: Authorization/Referral Documentation Included
*
Yes
Reviewer Notes
Audit Completion Status
*
Please Select
Complete
Incomplete
Pending
Submit Checklist
Should be Empty: