Highmark MM-171 2017-2025 free printable template

URGENT CARE CENTER/MEDICAL AID UNIT (MAU) & RETAIL CLINIC APPLICATION GENERAL INFORMATION Legal Name: DBA Name: Applications must include current copies of the following documents Federal Tax ID Number:National

How to fill out Highmark MM-171

How to fill out Highmark MM-171

1. Start with the patient’s personal information, including name, address, and date of birth.
2. Provide the patient’s insurance information, including policy number and group number.
3. Fill out the details of the healthcare provider, including their name, address, and provider identification numbers.
4. Indicate the type of claim being submitted (e.g., medical, dental, vision).
5. Enter the services rendered, including dates of service, procedure codes, and descriptions.
6. Include any additional required documentation or information as specified by Highmark.
7. Review all filled-out sections for accuracy and completeness.
8. Sign and date the form before submission.

Who needs Highmark MM-171?

1. Patients seeking reimbursement for healthcare services.
2. Healthcare providers submitting claims for payment from Highmark insurance.
3. Individuals covered by Highmark insurance who need to verify their medical expenses.

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What is Highmark MM-171?

Highmark MM-171 is a specific form used for reporting certain medical services and claims information required by Highmark, a health insurance provider.

Who is required to file Highmark MM-171?

Health care providers and organizations that are submitting claims or need to report medical services to Highmark are required to file Highmark MM-171.

How to fill out Highmark MM-171?

To fill out Highmark MM-171, providers should provide accurate patient information, service details, and billing codes as specified in the form instructions. Ensure that all mandatory fields are completed.

What is the purpose of Highmark MM-171?

The purpose of Highmark MM-171 is to facilitate proper claims processing and ensure accurate reporting of medical services provided to patients covered by Highmark insurance.

What information must be reported on Highmark MM-171?

Information that must be reported on Highmark MM-171 includes patient demographics, service dates, procedure codes, diagnosis codes, and any other relevant billing information.