For reconsideration of denied or reduced payment, please respond by submitting the following form.
Should you have further questions, please contact CompIQ Corporation Provider Services at (949) 770-7828 ext 15, or fax (949) 770-7428.
Inquiry Form
Type of request:
Make a Selection
Check Status
Review Appeal
Request EOR
*
Claim Number:
Document Ctrl No.:
Patient Last Name:
Patient First Name:
*
Date of Service:
(e.g. 06/01/01)
*
Tax ID Number:
Provider Contact Name:
E-mail:
Phone Number:
Fax Number:
Inquiry or Comments:
2 South Pointe, Suite 100, Lake Forest, CA 92630
tel 949-770-7828 fax 949-770-7428
