NEW CASE SUBMISSION

HIPAA secure online forms

RBP SUPPORT SERVICES

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.

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TRANSPLANT AND SPECIALTY FORM

Use this form to make a referral for Transplant or Specialty providers, as well as non-contracted providers for ad-hoc negotiations. 6 Degrees Health is utilizes many contracting methodologies including bundled case rates, per diems and metric-based pricing.

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COST CONTAINMENT CLAIM FORM

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.

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