HIPAA Secure Case Submission Forms

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

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Cash Prepay Form

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.

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.

Transplant & Specialty Patient Form

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.

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. 6 Degrees Health works to mitigate catastrophic claim risk using metrics that include metric-based pricing, clinical audit and medical necessity.

Clean Claims Review Form

Use this form to submit a claim for a clinical review. Please submit all claims with any additional supporting claim documentation you have received including Itemized Bill, Plan documents, UR/UM notes, Medical Records, Prior Denials. 6 Degrees Health evaluates every line item to identify and eliminate errors or inconsistencies and ensure savings are realized before the bill is issued.