Requestor Information: (Person/Company requesting the review)
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Responsible Party: (Person/Company responsible for the invoice if different from the above)
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Claimant Information:
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Type of Referral Requested:(Choose ONE from each Column)
Tier 1:Bill Review only, no Report
Tier 2:Bill Review and Report by a CPC
Tier 3:Bill Review and Report by a Nurse CPC
PIP Fee Schedule
Usual Customary and Reasonable
PIP Fee Schedule and UCR Comparison
*If previous payments/adjustments by other payers are noted in the billing or provided payment ledgers, PRIZM will take these into consideration during our analysis unless you specify you do not want them reviewed.
Referral Documents

Only PDFs accepted.

50MB maximum for all attachments.

 




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