Medical Record Submission

Please use this form to submit records requested by Health Plans via Remittance Advice.

Please Note: Only submissions for denied claims containing denial code(s) 251 or 252 with reason code(s) M127, N26, N228, N28, or N706 will be accepted. This form is not for Appeals, Disputes, or any other documentation submission.

* Indicates that the field is required.

Member Information

Member Name

Medical Record Number

Member Date of Birth

Member ID Number

Provider Information

Provider Name

Billing Provider NPI

Provider Contact Information

Provider Office Contact Name

Provider Office Contact Email

Provider Office Contact Phone Number

Office Contact Fax Number

Claim Information

Todays Date: 9/15/2026

Claim Number

Date of Service

Service Type

If documentation is required for both Medical and Pharmacy lines on claim then please submit a form for Medical and Pharmacy separately with the same claim number.

Medical

Pharmacy

Enter Claim Notes

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Medical Record Submission

Member Information

Provider Information

Provider Contact Information

Claim Information

Upload File(s)

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