07/01/2010 MORC, Inc. Tracking Number

07/01/2010 MORC, Inc. Tracking Number:

Macomb-Oakland Regional Center, Inc.

Exception Request

*TOP PORTION of thIS form must be completed AND SIGNED BY PROVIDER or it MAY be returned as incomplete.*

Provider Name: / Service Location:
Individual Name(s)
& MRN Number(s): / COFR:
Additional Name(s)
& MRN Number(s): / COFR:
Date Of Service: / Number Of Units Requested: / Unit Rate:
Description/Justification For Exception Request:
Total Amount Requested:

______

Provider Signature Date

In accordance with the Attachment A of the MORC, Inc. contract, Providers are required to submit clean claims (free of errors) by the 5th business day following the end of the service month. Any claims rejected are required to be resubmitted for payment by the end of the second calendar month following the service month. Any claims submitted beyond the second calendar month will be considered late claims. MORC is not responsible for paying late claims to providers.

EXCEPTION FOR END OF FISCAL YEAR: Providers are required to submit clean claims or resubmit rejected claims for the respective fiscal year by the 20th calendar day after the close of the MORC fiscal year (September 30th). Any claims submitted or resubmitted after the 20th will be considered late claims. MORC is equally not responsible for payment of late claims for end of fiscal year purposes.

*BOTTOM PORTION OF THIS FORM IS TO BE COMPLETED BY MORC, INC.*

 Clinical Approval

______ Clinical Disapproval

Clinical Director Signature Date

 Contracts Approval

______ Contracts Disapproval

Contract Manager Signature Date

 Final Approval

______ Final Disapproval

MORC Authorizing Signature Date

CPT Code: / Number Of Units Approved: / Rate:
Total Amt. Approved: / Date Entered Into EDGE:
Initials: / EDGE Authorization Number: