Rev 8/15 Reviewed 2/18
Transplant Stage Invoice Cover Sheet
Date:
Mail or deliver to:
AHCCCS /DHCM/Reinsurance Unit
701 East Jefferson Street
Mail Drop 6100
Phoenix, Arizona 85034
Fax 602-417-4725
Contractor Name (Health Plan or Program
AHCCCS ID # for Contractor and Facility
Submitted By
Contact Phone Number
E-mail address
Recipient Name
Recipient AHCCCS ID #
AHCCCS Transplant Case Number
Stage Description
Stage Number & Stage Name
Stage Dates of Service
Total Billed Charges for Stage
Contractor Paid Amount
Box A1
Listing of Non-payable charges due
to OPFS: CRN(s) listed in numerical
order by form type
Box A2
Listing of Denied Services CRN(s)
listed in numerical order by form
type
Reinsurance Action
Request Form Attached
Yes or No
Total $ Total $
Submissions must include the following:
Facility Invoice, Proof of Payment, Facility Claims (totaled by form type), Letter of Agreement
(if place of service is a non-contracted facility)
Box B minus Box A2 must equal Box C
Box B TBC from Attached Claims Box C TBC from PMMIS Screen
Attached Form I Total $ RI115 Form I Total $
Attached Form O Total $ RI115 Form O Total $
Attached Form A Total $ RI115 Form A Total $
Attached Form C Total $ RI115 Form C Total $
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