Get Form 1455

Completing Form 1455 online is a straightforward process that involves providing essential information related to provider disputes. This guide will assist you in navigating each section of the form to ensure a smooth and efficient filing experience.

Follow the steps to successfully fill out the Form 1455 online.

1. Click the ‘Get Form’ button to access the form and open it in your chosen browser or PDF editor.
2. Enter the provider name in the designated field marked with an asterisk (*), indicating it is a required field.
3. Input the provider tax ID number or Medicare ID number in the specified section, ensuring accuracy as this is also a required field.
4. Fill in the provider address, ensuring all details are complete and accurate.
5. Select the provider type from the options provided (e.g., MD, Mental Health, Hospital, Home Health, etc.). If you select 'Other,' please specify the type.
6. For the claim information, choose whether it pertains to a single claim or multiple 'LIKE' claims, and provide the number of claims if applicable.
7. Fill out the patient information, including the patient's name and health plan ID number that are marked as required.
8. Input the date of birth for the patient in the appropriate section.
9. Provide the original claim ID number, and for multiple claims, make sure to refer to the attached spreadsheet.
10. Record the service 'from/to' dates, as these are required for billing and reimbursement of overpayment disputes.
11. Complete the section regarding the original claim amounts billed and paid, which is necessary for dispute resolution.
12. Select the type of dispute you are filing—make sure to be specific in your selection.
13. Enter a detailed description of the dispute in the appropriate field and outline the expected outcome directly beneath it.
14. Provide your contact information, including your name, title, phone number, and, if applicable, fax number.
15. Review all information for accuracy, then sign and date the form.
16. If you have additional information to attach, check the box as instructed—but do not staple any attachments.
17. After completing the form, you may save your changes, download, print, or share the form as needed.

Start filling out the Form 1455 online today to ensure your provider dispute is addressed efficiently.