Reimbursement Denial Letter and Appeal Notification - Pr

World Trade Center Health Program Enrollment, Appeals & Reimbursement

App TT Reimbursement Appeal Decision Letter

Reimbursement Denial Letter and Appeal Notification - Providers

OMB: 0920-0891

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W orld Trade Center

Health Program


Form Approved

OMB No. 0920-0891

Exp. Date XXXXXX




Date


Re: Claim appeal / Pricing appeal / Name of specific appeal for claim # xxxxxx


Name of person sending in appeal

Address


This correspondence addresses your letter of appeal dated xxxxx, 2016 for claim # xxxxxxxxxxxxx. The appeal letter reads:


Quote the appeal letter / document.


Provide appeal decision. Explain response.


  • Pricing:


  • Backdating certification:


  • Adding code to Codebook:


  • Others as applicable:


Include any supporting documentation such as FECA Fee Schedule for pricing appeals or Codebook for the respective code and date.


The Office of Workers’ Compensation FECA fee schedule file can be retrieved here: https://www.dol.gov/owcp/regs/feeschedule/fee/fee15/fs15_code_rvu_cf.pdf.


The Office of Workers’ Compensation Geographic Practice Cost Index file can be retrieved here:

https://www.dol.gov/owcp/regs/feeschedule/fee/fee15/fs15_gpci_by_msa-ZIP.pdf.




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Regards,


<Reviewer Name>

Medical Claims Review Nurse

World Trade Center Health Program


[email protected]

888-982-4748






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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleWTC Weekly CCB Agenda
AuthorWTC PMO
File Modified0000-00-00
File Created2022-01-07

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