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Bureau of Health Services Financing (Medicaid)
Encounter Inquiry/Review Request

Encounter Inquiry/Review Request

Please use the form below when requesting a review of claims or encounters. While all fields may not be necessary for every review, please include all required fields and as many optional fields and details as possible to help expedite the review.

Short Description of Issue

Requestor Type

Requestor Entity Name

Requestor E-Mail Address

Requestor Phone Number

Date of Submission

Edit Codes Separate codes with a comma

Provider Type(s) (optional)

CPT/HCPCS/ Revenue Code(s) (optional) Separate codes with a comma

Diagnosis Code(s) (optional) Separate codes with a comma

Description of Issue Please provide a description of the issue needing investigation.

Total Count of Impacted Claims or Encounters

Total Dollars of Impacted Claims or Encounters

ICN Examples (list at least 5)

If you have additional documentation to submit with your review request, please send it to [email protected]. Be sure to use the short description above as the subject line of your email and check "Yes" below. Yes
No

Surgeon General Ralph L. Abraham, M.D.

Secretary Bruce D. Greenstein

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