Claim Cancellations
Fax: (212) 780-0412
To: / Claim Cancellation Unit, MultiPlan
Phone: (800) 546-3887 /
Email:
From: / First Name: / Last Name:
Organization:
Phone Number: / Fax Number:
Email:
Date: / Number of pages (including cover):
MultiPlan Claim Number: / (VERY IMPORTANT)
Total Charge:
MultiPlan Client Code: / Date of Service:
Patient Name:
First / Last
For MutiPlan Use Only - Case #:
Reason for Cancellation (please check one) ü
¨ / Applied toward deductible (10326) / ¨ / Patient paid entire bill (10336)
¨ / Benefits maximum reached (10327) / ¨ / Pre-dates agreement (10335)
¨ / Billed in error (10342) / ¨ / Replacement claim sent (90040)
¨ / Client’s liability less than rates (10301) / ¨ / Repriced using wrong client (90033)
¨ / Client paid liability without discount (10304) / ¨ / Repriced using wrong provider (90041)
¨ / Did not use rate (10318) / ¨ / Savings with other PPO (10306)
¨ / Duplicate case* (10312) list other case number below / ¨ / Sent in error (10330)
¨ / Provider did not accept discount (10302) / ¨ / Used direct rate (10309)
¨ / Ineligible (10308)
¨ / No payment made to provider (10320)
¨ / No rate at this hospital (10333)
¨ / No rate for services (10322)
¨ / Not our member or not in system (90039)
¨ / Other insurance primary (10314)
¨ / Other reason / explain below (10350) / * Duplicate case refers to a single claim repriced under two different case numbers.
/ Comments/Explanations: