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Home
About Us
About Us
ICS Star
Management Team
Event Calendar
Our Affiliations
Career Opportunities
Company News
Our Services
24/7 Call Center
Nurse Case Management
Prospective Concurrent Retro UR Programs
New Jersey AICRA
Medical Bill Review & PPO ICING
Third Party Demand Package Review
MSP Compliance
Medical Necessity File Review
Vocational Rehabilitation Case Management Services
Reporting & Regulatory Compliance
Request Service
Request a MSA Allocation Service
Request a CMS Submission Service
Request a Conditional Payment Review Service
Request a Nurse Case Management Service
Request a Third Party/Demand Package Medical Bill & Nurse File Review Audit Service
Request a First Party Medical Bill Review Audit Service
Request a Vocational Rehabilitation Service
Contact Us
Service Referral
Service Referral
"
*
" indicates required fields
Referral Type
*
Nurse Case Management
Third Party Demand Package Review - Level I - Medical Bill Repricing
Third Party Demand Package Review - Level I & II - Medical Bill Repricing & Nurse Medical Necessity Audit & Review
First Party Medical Bill Review Audit Service
Vocational Rehabilitation
Other
Other (please specify)
Referral Date:
*
MM slash DD slash YYYY
Referred By
*
TYPE OF CLAIM – PLEASE CHECK ONE
*
Workers' Compensation
Liability
Auto No Fault
Claimant/Injured Worker Last Name
*
Claimant/Injured Worker First Name
*
M.I.
*
M
F
Claimant/Injured Worker's Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
SSN:
Employer:
Employee ID:
Claim Number:
*
Date of Birth:
*
MM slash DD slash YYYY
Date of Injury:
*
MM slash DD slash YYYY
Occupation:
ATTENDING PHYSICIAN
Attending Physician:
Physician Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
ACCOUNT INFORMATION
Client:
*
Assigned Claims Adjuster:
*
Adjuster Phone Number
Adjuster Email Address
*
Defense Attorney Name:
Attorney Email Address
Attorney Phone Number
Plaintiff Attorney Name:
Attorney Email Address
Attorney Phone Number
Primary Diagnosis Code and Description
SPECIAL INSTRUCTIONS & NOTES
SPECIFIC CLAIM DIRECTIVES
Upload File
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, docx, doc, Max. file size: 256 MB, Max. files: 20.
If making a Third-Party Demand Package Level I referral, please include all the Medical Bills inclusive of UB04 forms, as applicable. If making a Third-Party Demand Package Level II referral, please include all Level I items plus additional documentation such as Supporting Medical Records, Police Report, Accident Investigation, Prior Medical History to assist the Nurse in their Audit & Review for Medical Necessity.
Please note, maximum number of files you can upload is 20.
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To learn more about our services, please call (732)-384-3430