Participating Provider Claim(S) Review Request Form

Participating Provider Claim(s) Review Request Form

We have created the Participating Provider Claim(s) Review Request Form (the "Form")to help improve the process of corresponding with us regarding claim disputes/appeals, general claim questions, or to submit a corrected claims. With your cooperation in completing the form in its entirety, we will be able to recognize the purpose of your communicationand direct the information to the correct department to better ensure a timely resolutionof the issue.Although we intended to make the use ofthis form mandatory beginning on January 1, 2007, we understand that with any change there is a period of adjustment. To allow you and your office staff additional time to adjust to using the Form, we are extending the date that use of the form will become mandatory. Beginning on July 1, 2007, Oxford will no longeraccept correspondence and documents from providers regarding claim disputes/appeals, general claim questions, or to submit a corrected claim without the submission of a fully completed Form (which includes all necessary information for review). Anycorrespondence or documents submitted without the form after this date will be returned to your office.

In addition to the links in this message, the Form is available after you log in. You may access this form by clicking on the Tools & Resources tab and then onthe Formslink under "Manage Your Practice". If your intention is to appeal a claim issue, youmust check off the box labeled "appeal" on the form or the issue willbe considered an inquiry. The form includes detailed instructions for each section of the form to help you clearly communicate the intent of your request.

TheNew Jersey Provider Appeal Form must be used to submit your own appeals regarding claim determinations for services rendered to Members with a benefit plan issued in the state of New Jersey. This required form isalso available thoughthe use of theTools & Resources tab and the Forms link after you log in.The timeframe for submitting a New Jersey regulated appeal to Oxford is 90 days. Please remember that the Participating Provider Claim(s) Review Request Form must be used to submit corrected claims, general claim questions and member appealsfor Members with a benefit plan issued in the state of New Jersey.