Payer Plan Request Form

Use this form to submit a request to create a new or update an existing Epic Payer and/or Plan (EPM/EPP). Submission of this form will automatically create an IS Service Request and be routed to the proper IS resources.
DO NOT include any Protected Health Information (PHI) on this form.

By checking this box, I am verifying that I am an Authorized Requestor in a manager/director role or a designated authorized requestor. *

Confirm

Requestor name (first and last): *

Requestor position: *

Requestor email: *

Requestor phone number: *

Is this request for a new or existing Payer and/or Plan? *

Payer name: *

Plan name: *

Financial class: *

Effective date: * +

Address: *

Phone: *

Fax: *

Synonyms: *

Product type: *

Is this a PB only Payer/Plan? *

At what level will the address be determined? *

Days until timely filing: *

Appeal days: *

Will claims be sent electronically? *

Institutional EDI#: *

Professional EDI#: *

Additional Information (contracts, HB labs, 3M data, etc.): *

Existing Payer name: *

Existing Payer ID: *

New Plan address: *

New Plan name: *

New Plan phone: *

New Plan fax: *

New Plan effective date: * +

New Plan synonyms: *

New Plan product type: *

At what level will the address be determined? *

Is Existing Payer currently set up for RTE (Real Time Eligibility)? *

Will claims be sent electronically? *

Institutional EDI # (HB): *

Professional EDI # (PB): *

Additional Information (contracts, HB labs, 3M data, NDC, etc.): *

Change scope: *

What will this update apply to? *

Existing Payer name: *

Existing Payer ID: *

Existing Plan name: *

Existing Plan ID: *

Provide detailed information regarding requested change: *