Provider Services

Check Claims, Benefits and Eligibility!

Contact our Provider Services Department any time Monday through Friday
between 7 a.m. and 6 p.m. EST by using the phone number listed on
the member's ID card or by calling one of these numbers:

Provider Inquiry: 800/362-1279

Electronic Claims: 800/321-7223

Electronic Referrals: 800/733-3706

Or send correspondence by mail to:
Medical Mutual
P.O. Box 94917
Cleveland, OH 44101-4917

Provider Action Request Form

Please fill the form out completely. Any blanks or incomplete information could delay or cause your request to be returned unprocessed.

You may also submit your information via U.S. Mail. Simply download the PDF version of the PAR Form and send it to us.

• PAR Form & Instructions

To view the Portable Document Format files (PDFs) on this site, download a free Acrobat Reader.

Fields marked with * are required.

Provider Information
*Requester/Contact Name:
*Provider Email Address:
*Telephone Number:
*Nine Digit Tax Number:
NPI Number:
*Provider Name:
*Address:
*City:
*State:	Select a state AL-Alabama AK-Alaska AZ-Arizona AR-Arkansas CA-California CO-Colorado CT-Connecticut DE-Delaware FL-Florida GA-Georgia HI-Hawaii ID-Idaho IL-Illinois IN-Indiana IA-Iowa KS-Kansas KY-Kentucky LA-Louisiana ME-Maine MD-Maryland MA-Massachusetts MI-Michigan MN-Minnesota MS-Mississippi MO-Missouri MT-Montana NE-Nebraska NV-Nevada NH-New Hampshire NJ-New Jersey NM-New Mexico NY-New York NC-North Carolina ND-North Dakota OH-Ohio OK-Oklahoma OR-Oregon PA-Pennsylvania PR-Puerto Rico RI-Rhode Island SC-South Carolina SD-South Dakota TN-Tennessee TX-Texas UT-Utah VT-Vermont VA-Virginia WA-Washington WV-West Virginia WI-Wisconsin WY-Wyoming
*Zip Code:

Patient Information
*Identification Number:
*Patient Name:
*The Company Claim Number:
*Service Date(s) Questioned:
*Services provided in:	Select a state AL-Alabama AK-Alaska AZ-Arizona AR-Arkansas CA-California CO-Colorado CT-Connecticut DE-Delaware FL-Florida GA-Georgia HI-Hawaii ID-Idaho IL-Illinois IN-Indiana IA-Iowa KS-Kansas KY-Kentucky LA-Louisiana ME-Maine MD-Maryland MA-Massachusetts MI-Michigan MN-Minnesota MS-Mississippi MO-Missouri MT-Montana NE-Nebraska NV-Nevada NH-New Hampshire NJ-New Jersey NM-New Mexico NY-New York NC-North Carolina ND-North Dakota OH-Ohio OK-Oklahoma OR-Oregon PA-Pennsylvania PR-Puerto Rico RI-Rhode Island SC-South Carolina SD-South Dakota TN-Tennessee TX-Texas UT-Utah VT-Vermont VA-Virginia WA-Washington WV-West Virginia WI-Wisconsin WY-Wyoming

Type of Request

Explanation required for all the following, except Medical review.

Medical review (records attached) Explanation:

Claim review Explanation:

COB Explanation:

Corrected billing Explanation:

Duplicate payment or denial Explanation:

Requested information attached Explanation:

Timely filing Explanation:

Pricing/Traditional Amount review Explanation:

DRG/aPG/Outlier Explanation:

Professional Providers

PLEASE CONTACT THE APPROPRIATE OFFICE LISTED BELOW FOR QUESTIONS CONCERNING:

• Contracting with Medical Mutual
• Administrative policies/procedures including referrals and precertification

Find a Provider

Maximize your cost savings and avoid unexpected charges by finding providers in the Medical Mutual network.

Find a Provider

Featured Content

Report Fraud

Fraud detection has saved Medical Mutual members $58 million since 1983. If you suspect fraud, Medical Mutual wants to know.

Report Fraud

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