Case Intake Form

 HIPAA Secure Case Intake Forms

 

Use this form for a procedure going through our Cash Prepay Program. This program allows 6 Degrees Health to negotiate cash upfront prices for planned procedures. It provides full transparency and eliminates billing surprises. The Plan must be enrolled in our Cash Prepay Program prior to accepting any referrals.

Use this form for new cases with employer-sponsored health plans enrolled with 6 Degrees Health for repricing facility and/or professional claims. Cases could be access issues, balance bills, appeals, or single case agreement requests.

 

Use this form to submit a claim to our Cost Containment department for charge, billing & coding and/or clinical audit review. Please submit any supporting materials you have such as:  UB-04, CMS 1500, IB, Plan Benefit Language, Discharge Summary, Medical Records, etc.  6 Degrees Health works to mitigate catastrophic claim risk using metrics that include metric based pricing, UCR, clinical audit and medical necessity.

Use this form to make a referral to one of our contracted Transplant or Specialty providers, as well as, non-contracted providers for ad-hoc negotiations.  6 Degrees Health is able to use our proprietary data and utilize many contracting methodologies including bundled case rates, per diem and metric based pricing.

Be sure to click SUBMIT when the form is complete, otherwise 6 Degrees Health will not be notified of your request.