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Get Dispute Resolution Form 2011-2026
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How to fill out the Dispute Resolution Form online
Filling out the Dispute Resolution Form online can be a straightforward process if you follow the provided instructions carefully. This guide offers a comprehensive overview of each section of the form to support you in completing it accurately and effectively.
Follow the steps to fill out the Dispute Resolution Form online.
- Click 'Get Form' button to obtain the form and open it in your preferred editor.
- Review the instructions at the top of the form to ensure you meet the criteria for filing a dispute. Pay special attention to the requirements regarding the exhaustion of internal appeals and deadlines for filing.
- Complete the 'Physician Information' section by entering the treating physician's name, tax identification number, billing address, telephone number, contact name, fax number, and contact phone number as listed on the claim.
- In the 'Claim Information' section, provide the member's name, member ID number, contact email, member group number, and member address.
- Fill out the request for physician billing dispute by indicating the date of service and the case number as shown on Aetna's appeal letter.
- Specify the amount in dispute, which is the additional amount you believe Aetna should have paid. Ensure this amount exceeds $500 or provide information regarding the aggregate claims if applicable.
- Indicate the filing fee based on the amount in dispute. Ensure to check the appropriate box for the filing fee and note the total amount you are enclosing.
- Acknowledge the terms of the External Billing Dispute Resolution Review and certify the accuracy of the submitted information by signing and dating the form.
- Attach all supporting documentation relevant to the dispute, ensuring that any previously submitted documents are not resubmitted. Only submit new materials not previously provided.
- Submit the completed form, along with all supporting documentation and the filing fee, to IMEDECS at the address provided on the form.
Complete your Dispute Resolution Form online today to ensure your billing dispute is reviewed.
Developing a dispute resolution process begins with outlining the steps involved in resolving conflicts. Ensure you incorporate the use of a Dispute Resolution Form to facilitate communication and documentation. Regularly review and adjust your process based on feedback and outcomes to enhance its effectiveness.
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