Form 3078 is used to return to the provider claims that cannot be processed for payment and notify the provider of the deadline date for claim resubmission, if applicable.
When to Prepare
Complete an original and one copy of Form 3078. Issue the original and any corresponding claim or Form 3081, Appellant – Provider Assignment, to the provider. File the copy in the case record.
Maintain at least until the end of the third complete state fiscal year following the date on which Form 3078 is submitted.
To – Enter the provider’s name, mailing address, city, state and ZIP code in the fields provided.
From – Enter the office name, mailing address, city, state and ZIP code in the fields provided.
First Date Original Claim Received – Enter the first date the original claim was received.
Date Form 3078 Issued – Enter the date Form 3078 was issued.
Patient’s Name – Enter the patient’s name.
CIHCP Case Record No. – Enter the CIHCP case record number.
Check Box Items – Check all boxes 1 through 11 with the appropriate reasons why the claim cannot be processed for payment.
This claim may not be resubmitted – Check the box if the claim may not be resubmitted.
If the above-checked items are corrected, this claim may be resubmitted and Date – Check this box if the claim may be resubmitted and enter the deadline date for resubmittal.
Contact our office at – Enter the office area code and phone number.
Staff Signature – Staff member completing the form signs the form.