Claim Rejection Support for Office Therapy

Please complete the following form to expedite your support request related to claims rejections
and Office Therapy Claims Manager for Office Therapy 10 ONLY.

ISSUES REPORTED USING THIS FORM, OTHER THAN CLAIM REJECTIONS AND CLAIM MANAGER
WILL NOT BE PROCESSED. Use the following form to report any other issues.
http://www.quicdoc.com/support_form.htm

Before submitting this form, you can search our Knowledgebase to see if your issue has a solution.

Customer Name:

Customer Phone:

Customer EMail:

Contact Person:

Electronic Claim Type: 50104010   

Clearinghouse Name:    Contact Information (Name and Phone):

If using Gateway EDI for Clearinghouse, please specify your Site ID:

Payor (for which rejections are occurring):

Rejection Details
In order for us to provide you superior support we need to know all of the details that you
have concerning the rejection. Please provide any and all reasons for rejection and any loop
and segment details (Example: Loop 2010AA Segment NM1-09 data missing) that you received
from your clearing house or payer - to help us troubleshoot your rejections quickly and efficiently.