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Out-of-Network Data Request and Response Form
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NAME OF REQUESTING PROVIDER/FACILITY AND CONTACT INFORMATION:INSTRUCTIONS:
All fields must be completed to submit this form.
If more claims information are needed please add rows to the table

Providers/facilities: Please fill out the columns B-K starting on row 10
Carriers: Please fill out the corresponding rows starting in column L
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REQUESTING PROVIDER OR FACILITY TIN:
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NAME OF CARRIER AND CONTACT INFORMATION:
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DATE OF REQUEST:
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REQUESTING PROVIDER DATA FIELDS (must be completely filled-out by requester)CARRIER DATA FIELDS (must be completed by carrier)*
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Carrier Member NumberCarrier Claim NumberPatient Account NumberDate of ServiceCPT/HCPCS CodeUnitsTotal Facility/Provider ChargesTotal Amount PaidDate Claim PaidCO DOI Regulated Plan? Y/NDOI Geographic Rating AreaCarrier Provider Methodology Calculation:

60th Percentile of Average In-Network Rate - APCD Data		Carrier Provider Methodology Calculation:

110% of Carrier Median In-Network Rate		Carrier Facility Methodology Calculation:

Median In-Network Rate - APCD Data		Carrier Facility Methodology Calculation:

105% of Carrier Median In-Network Rate		Other Negotiated Amount (if applicable)Amount Paid to Include Member Cost Sharing
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*Carriers may be subject to the imposition of penalties, or any sanctions authorized by the insurance code for providing false or misleading information in completing this form.
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Please refer to Division of Insurance regulation 4-2-79
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