Research and Review

Please complete the form below, describing your claims issue. You may fill this out online and submit the form to MHN. Alternatively, you may print the blank form, fill it out and fax it to MHN at (877) 719-4804. Please fill out all fields and be as specific as possible. Please also note whether you have had contact with MHN about this issue and, if so, with whom you have spoken.

Overpayment Recovery Procedures

Research and Review Form

* Required field(s)

Provider Name *

Federal Tax ID# *

Provider Contact Information

Email Address

Fax

Daytime Phone *

Member Information

Patient Name

DOS(s) in Question

Claims Issue (Please Check One)

No Response Received on Claim Claim Denial Disputed Incorrect Payment Received Other (please give brief description)

Description of Problem

Additional Comments