Get Provider Dispute Form - Uhccommunityplan.com

Filling out the Provider Dispute Form online is an essential process for healthcare providers seeking to request a claim reconsideration. This guide provides clear, step-by-step instructions to help users navigate the form efficiently and effectively.

Follow the steps to complete the Provider Dispute Form online.

1. Press the ‘Get Form’ button to obtain the Provider Dispute Form. This action will allow you to access the form in an editable format.
2. Begin by entering the member information. Fill in the Member ID, Control/Claim Number, Date of Service, Billed Amount, Member Name (Last, First, MI), Street Address, State, and Zip Code.
3. Continue to the patient details section. Include the Patient Name (Last, First, MI) and ensure all information is accurate.
4. Next, provide your information as the healthcare provider. Fill in your Tax Identification Number (TIN), Phone Number, Email Address, and your name as listed on the Provider Remittance Advice (PRA) or Explanation of Benefits (EOB).
5. Specify the reason for your request by checking the appropriate box. You can select options such as 'Previously denied/closed as “Exceeds Filing Time”,' and provide supporting evidence as needed.
6. Detail any comments or expectations regarding the claim outcome. Clearly outline what you are seeking from UnitedHealthcare Community Plan to resolve the issue, including any dollar amounts, if applicable.
7. Ensure all required attachments are included. This includes a copy of the PRA or EOB, the claim form (with corrections, if necessary), and any other supporting documentation as specified.
8. Review all information for accuracy. Once you have confirmed that the form is complete, you can save any changes, download, print, or share the form as necessary.

Complete your documents online today for a smoother claims process.