Medical Mutual - Health Plans for Life

How do I inquire about or appeal a claim?

The PAR Form is used for all provider inquiries and appeals related to reimbursement. Providers may request corrective adjustments to any previous payment using this form. Medical Mutual will review the requests and make adjustments within 12 months from the date the initial claim was processed.

How to submit the PAR Form:

  • Log in to the Provider Portal and select the claim you need to inquire about in the Claims & Eligibility feature. Then, click the “Submit Inquiry” button to complete the necessary information and attach the appropriate files.
  • Fill in the required information below and attach any related medical records.

Note: Please use one form per patient or inquiry. Any fields with incomplete information may delay or cause your request to be returned unprocessed.

Questions or Postal Mailings? Please reference the PAR Form Instructions to determine the supporting documentation required for each type of request or what to do when a claim is returned unprocessed.


Update: Per the “Claims Submission Process Change” article in
Q4 2016 Mutual News, we can no longer accept corrected claims through the Claims Inquiry feature of the provider Portal. Electronic corrected claims must be submitted as electronic replacement claims. Please resubmit your request by submitting the replacement claim electronically.

Fields marked with * are required.

Provider Action Request (PAR) Form

Provider Information

Requester/Contact Name:*

Provider E-mail Address:*

Confirm E-mail Address:*

Telephone Number:*

Nine Digit Tax Number:*

NPI Number:*

Provider Name:*

Address:*

City:*

State:*

 

Zip Code:*


Patient Information

Identification Number:*

Patient Name:*

Medical Mutual Claim Number:*

Service Date(s) Questioned:*


Type of Request


PLEASE NOTE: WE NO LONGER ACCEPT PAR FORMS FOR THE FOLLOWING:

COB – Primary Carrier payment info and Medicare Primary EOMB info must be submitted electronically.
Corrected/Replacement Claim/Late Charges – Must be electronically submitted using TOB XX5 or XX7.


Reason for Inquiry:

Attach Documentation
(if applicable)

Attachment File Size Must be less than 10MB




      
I would like to receive a confirmation email from Medical Mutual that my form was submitted.


Contact Information


If you have any questions regarding contracting, provider inquiry or other administrative policies and procedures Contact Us at the appropriate location.

This Medical Mutual website may contain links to other Internet sites (“Third Party Sites”) that are not maintained by or under the control of Medical Mutual. These links are provided solely for your convenience, and you access them at your own risk. Medical Mutual makes no warranties or representations about the contents of products, services or information offered in such Third Party Sites. Consequently, Medical Mutual is not and cannot be held responsible for the accuracy, copyright compliance, legality or decency of material contained in Third Party Sites linked to this Medical Mutual website.

© 2017 Medical Mutual®