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Form Name

PDF Form File

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SQL Query (.sql files added to queries folder will appear on this list)

select * from foersom

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Completed PDF Form

PDF Form Field Name	SQL Field Name
Date
Utilization Management
Adverse Determination (Medical Necessity
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Type: Authorization Precertification
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Authorization or Precertification Number
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Coordination of
Provider
Corrected Claim/Late
Timely
Reconsideration Reference #
Provider Name
Florida Blue Number
City
State
Zip
Tel. #
Fax #
Contact Name
Patient Last Name
Patient First Name
Contract/ID # (alpha & #s)
Patient Date of Birth
Claim Number
Billed Amount
From
To
Procedure Code(s):
Appeal Reason
NPI # Florida Blue #
Street Address