MedCost, LLC Physician & Providers Claim Status Request Form

MedCost's Payer Service Team is available to assist with claims in which you have exhausted all efforts to resolve and are 60 days after the MedCost repricing date.

You can submit claim inquiries via this secure online claim status inquiry form. Please note that response to this status inquiry is not automatic. You will receive responses to your inquiries daily via fax until all inquiries have been resolved.

This form is only for MedCost participating providers.

Your FULL and COMPLETE information is required to obtain a response from our research unit.

Name(full name of sender)

Practice/Facility Name

Street Address

City, State Zip

FTID

Phone Number (include area code)

Fax Number

Email Address

CLAIM # 1

Employer Group Name

Employer Group Policy #

Patient's Full Name
(as filed on claim)

Insured/Patient ID#
(as filed on Claim)

Date of Service

Total Charges Billed

What Action is requested from MedCost at this time?

Problematic Claim Research

Payment Discrepancy

(fill choice in with X)

REQUIRED INFORMATION:
Please list all steps taken by your office to obtain status with the claim administrator. Please include all dates.

CLAIM # 2

Employer Group Name

Employer Group Policy #

Patient's Full Name
(as filed on claim)

Insured/Patient ID#
(as filed on Claim)

Date of Service

Total Charges Billed

What Action is requested from MedCost at this time?

Problematic Claim Research

Payment Discrepancy

(fill choice in with X)

REQUIRED INFORMATION:
Please list all steps taken by your office to obtain status with the claim administrator. Please include all dates.

CLAIM # 3

Employer Group Name

Employer Group Policy #

Patient's Full Name
(as filed on claim)

Insured/Patient ID#
(as filed on Claim)

Date of Service

Total Charges Billed

What Action is requested from MedCost at this time?

Problematic Claim Research

Payment Discrepancy

(fill choice in with X)

REQUIRED INFORMATION:
Please list all steps taken by your office to obtain status with the claim administrator. Please include all dates.

PRINTABLE PDF VERSION

You may also print this form and fax to our Payer Service Team with attachments to assist our research. (e.g.: a copy of the explanation of benefits for payment discrepancy requests)