Get Pdr Request Form.doc - Lacare

This guide will provide you with clear instructions on how to successfully fill out the Provider Dispute Resolution Request Form from Lacare online. By following this step-by-step process, you will ensure that your submission is complete and accurate.

Follow the steps to complete the PDR Request Form online.

1. Press the 'Get Form' button to access the Provider Dispute Resolution Request Form and open it in your preferred digital editor.
2. Fill out the required fields marked with an asterisk (*). Start with 'Provider Name,' 'Provider Tax ID # / Medicare ID #,' and 'Provider Address.' Make sure to provide accurate details.
3. Select the 'Provider Type' that best describes your practice from the available options such as MD, Mental Health, Hospital, Home Health, etc.
4. Input the 'Claim Information'. Indicate whether the claim is single or if it concerns multiple 'LIKE' claims by completing the attached spreadsheet when needed.
5. Complete the 'Patient Name' field and ensure the 'Health Plan ID Number' is accurately entered. If applicable, add the 'Patient Account Number.'
6. For disputes related to billing, ensure that the service 'From/To' date is correctly provided, as this is required for certain dispute types.
7. Identify the 'Dispute Type.' This may involve a claim dispute, appeal regarding medical necessity, contract dispute, or request for reimbursement of overpayment.
8. In the 'Description of Dispute' field, be as specific as possible regarding the issue you are disputing. Follow this by articulating your 'Expected Outcome' clearly.
9. Fill in your contact information by providing your name, title, phone number, and signature along with the date. If you are attaching additional information, indicate this in the specified box.
10. Once all the fields are complete and reviewed, save your changes. You may choose to download, print, or share the filled form as needed for submission.

Complete your documents online today and ensure a smooth submission process.