Get Provider Dispute Resolution Form - Anthem

This guide provides a comprehensive overview of how to fill out the Provider Dispute Resolution Form for Anthem online. By following these steps, users will be able to efficiently complete the form and submit their disputes with confidence.

Follow the steps to complete the form accurately

1. Use the ‘Get Form’ button to retrieve the Provider Dispute Resolution Form and open it in your preferred editing application.
2. Fill in the date (mm/dd/yyyy) at the top of the form to indicate when the request is being made.
3. In the 'Requestor Information' section, provide the necessary details: the provider's name, provider number or taxpayer identification number (TIN), office or practice name, contact person’s name, telephone number, fax number, and the complete address including city, state, and ZIP code.
4. Next, complete the 'Claim Information' section by entering the patient's name and ID number, the subscriber's name (including any applicable prefixes or suffixes), the claim number(s), dates of service, billed amount, and the disputed amount.
5. Indicate the process date and select any relevant clinical edits or bundling options. Provide any explanations in the space provided.
6. Select the reason for the dispute from the options provided, such as out-of-network, timely filing denial, or disagreement with the outcome of the claim action. You may also specify 'other' and explain.
7. In the 'Supporting Documentation' section, check all types of documentation being attached to support your dispute. If you're not sure what to attach, refer to your Provider Manual for guidance.
8. After completing all sections, review the form for accuracy. Once verified, you can save your changes, download the form, print it, or share it as needed.

Complete your Provider Dispute Resolution Form online today to ensure your dispute is processed efficiently.