Riverbend

Forms

Commonly used Audit and Reimbursement Forms

• Sanction Certification 
• Provider Contact Memorandum 
• Form 339-OPO/LAB Cost Report Reimbursement Questionnaire 

Rate Change Request Forms

Riverbend performs a rate review upon request and during the tentative review process. If a rate change is deemed necessary during the tentative process, providers will receive correspondence from the Intermediary requesting a change or more information.

Any changes in rates can be requested online by submitting a Rate Change Request Form no later than the 15^th of each month preceding the desired effective date. 

Rate Change Request Forms:

• OPO Form 
• Lab Form