Get Provider Resolution Request Form - Coast Healthcare Management ...

Completing the Provider Resolution Request Form is essential for addressing disputes with Coast Healthcare Management. This guide provides clear steps to assist you in accurately filling out the form online, ensuring that all necessary information is included.

Follow the steps to complete the form online effectively.

1. Press ‘Get Form’ button to obtain the form and open it in the editing interface.
2. Begin by entering your Provider NPI and Tax ID in the designated fields. These identifiers are critical for processing your request.
3. Fill in the Provider Name, Address, and select the Provider Type from the options available, ensuring to provide the appropriate details for accurate classification.
4. Next, navigate to the Claim Information section. Specify if this is a single or multiple ‘LIKE’ claims and provide the Date of Birth, Patient Name, and Health Plan ID Number where indicated.
5. Document the Original Claim ID Number and Service From/To Dates. Enter the Original Claim Amount Billed and Original Claim Amount Paid to clarify the financial details of the dispute.
6. Select the Dispute Type by marking the relevant options, such as Claim, Appeal of Medical Necessity, or Contract Dispute. Be precise in your choice for proper resolution.
7. In the Description of Dispute field, concisely outline the issue you are encountering, ensuring that you are specific in your account.
8. Clearly indicate your Expected Outcome to help the decision-makers understand what resolution you seek.
9. Fill in your Contact Name, Title, Phone Number, and the Date of submission. Ensure to include your signature for validation.
10. If you have additional information to support your dispute, check the box indicating attachments, and do not staple the documents before mailing.
11. Upon completing the form, save your changes. You can download, print, or share the form as required.

Take action now and fill out your Provider Resolution Request Form online today.