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Print Form Billing Dispute Resolution Request Form Provider Information Date Submitted Note All requests must pertain to a claim with dates of service that are within the timely filing guidelines. If the billing dispute pertains to a claim that is already past the timely filing limit no action will be taken* Provider Name NPI TIN Contact Person/Name Contact Number Patient/Beneficiary Information First Name Last Name HIC Number Date of Birth Claim Information Date s of Service Enter all that apply From Through DCN s Enter all that apply Note A separate form must be completed for each patient/beneficiary. Contact Resolution Information The following information is required to establish the provider s attempt to resolve the billing dispute prior to contacting Palmetto GBA for assistance. Name of Agency Contacted Method of Contact Date Agency Contacted Phone Letter Fax Other Name of Individual Contacted Is the agency out of business Yes No If yes please explain Identify the Situation Billing Overlap This situation applies to instances where two providers are billing for overlapping dates of service which may include a transfer situation* Palmetto GBA Page 1 October 2013 Include the following information with your inquiry Transfer Agreement Form Written communication with other provider if any Beneficiary Eligibility Verification HIQH/HIQA or OPS Screen Print Sequential Billing Additional Comments Mail or Fax the Complete Form To Attn Provider Contact Center - AG-840 P. If the billing dispute pertains to a claim that is already past the timely filing limit no action will be taken* Provider Name NPI TIN Contact Person/Name Contact Number Patient/Beneficiary Information First Name Last Name HIC Number Date of Birth Claim Information Date s of Service Enter all that apply From Through DCN s Enter all that apply Note A separate form must be completed for each patient/beneficiary. Contact Resolution Information The following information is required to establish the provider s attempt to resolve the billing dispute prior to contacting Palmetto GBA for assistance. Contact Resolution Information The following information is required to establish the provider s attempt to resolve the billing dispute prior to contacting Palmetto GBA for assistance. Name of Agency Contacted Method of Contact Date Agency Contacted Phone Letter Fax Other Name of Individual Contacted Is the agency out of business Yes No If yes please explain Identify the Situation Billing Overlap This situation applies to instances where two providers are billing for overlapping dates of service which may include a transfer situation* Palmetto GBA Page 1 October 2013 Include the following information with your inquiry Transfer Agreement Form Written communication with other provider if any Beneficiary Eligibility Verification HIQH/HIQA or OPS Screen Print Sequential Billing Additional Comments Mail or Fax the Complete Form To Attn Provider Contact Center - AG-840 P. If the billing dispute pertains to a claim that is already past the timely filing limit no action will be taken* Provider Name NPI TIN Contact Person/Name Contact Number Patient/Beneficiary Information First Name Last Name HIC Number Date of Birth Claim Information Date s of Service Enter all that apply From Through DCN s Enter all that apply Note A separate form must be completed for each patient/beneficiary. Contact Resolution Information The following information is required to establish the provider s attempt to resolve the billing dispute prior to contacting Palmetto GBA for assistance. Name of Agency Contacted Method of Contact Date Agency Contacted Phone Letter Fax Other Name of Individual Contacted Is the agency out of business Yes No If yes please explain Identify the Situation Billing Overlap This situation applies to instances where two providers are billing for overlapping dates of service which may include a transfer situation* Palmetto GBA Page 1 October 2013 Include the following information with your inquiry Transfer Agreement Form Written communication with other provider if any Beneficiary Eligibility Verification HIQH/HIQA or OPS Screen Print Sequential Billing Additional Comments Mail or Fax the Complete Form To Attn Provider Contact Center - AG-840 P.