Request a Duplicate Remittance Advice

Please allow at least 2 weeks from the Remittance Advice Mailed date before requesting a duplicate remittance advice.

Only the provider for whom the check is made payable may request a duplicate Remittance Advice (RA). No other requests will be honored.

NOTE: You can also retrieve Remittance Advices on the PROMISe™ Internet site. This feature provides you with the ability to access up to 2 years of PROMISe™ paper-based Remittance Advices. Remittance Advices are available back to March 1, 2004, or your first Remittance Advice produced via PROMISe™.

To request a Remittance Advice, complete the form below and click on the submit button at the bottom of the page.

PLEASE ALLOW 2 WEEKS TO RECEIVE YOUR REMITTANCE ADVICE AFTER SUBMITTING THIS REQUEST

The check must be from Department 021 (located at top left corner of check). Department 021 indicates the check is from the Department of Human Services, Office of Medical Assistance Programs.

 

Date: 5/22/18 (Automatically Completed)
I did not receive a copy of the Remittance Advice for Cycle:
Provider Name(as it appears on check):
Provider Email Address:
Address(as it appears on check):
Address RA to be sent to (if different than on check):

Complete this section if you are requesting an RA that was printed prior to March 1, 2004.
Provider Type:
Provider MAID Number:

-OR-
Group Type:
Group MAID Number:

Complete this section if you are requesting an RA that was printed on or after March 1, 2004.
PA PROMISe Provider #(s) - The format is (9-digit MPI Provider Number) + (4-digit service location)
  +  

Contact Person:
Contact Phone:(Ex. 717-555-1111)
RA being requested is for:
  Hard-Copy Check
  Electronic Direct Deposit
Check's Prep Date or Date of Electronic Direct Deposit: (MM/DD/YYYY)
*located at top left corner of check
Check Voucher Number (required for hard-copy checks):
*located to the right of check prep date
Amount of Check or Electronic Direct Deposit:
  Dollars     Cents
* The Dollar Field may have a value no larger than 9,999,999 and the Cent field may have a value no larger than 99. Please do not use commas or periods when filling in the check amount.

 

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