Get Provider Claim Dispute Form Use This Form As Part ... - Ambetter

This guide provides step-by-step instructions on how to complete the PROVIDER CLAIM DISPUTE FORM required by Ambetter from Buckeye Community Health Plan. Properly filling out this form is essential for disputing decisions made during the claims process.

Follow the steps to successfully fill out the PROVIDER CLAIM DISPUTE FORM.

1. Press the ‘Get Form’ button to access the PROVIDER CLAIM DISPUTE FORM and open it for editing.
2. Begin by entering the required information in the designated fields: fill in your provider name, tax ID number, and control/claim number. These details help identify your claim.
3. Provide the date(s) of service relevant to the dispute. Make sure these dates align with the service provided.
4. Enter the member's name and their RID number. This is essential for the processing of the claim dispute.
5. Select the reason for the dispute by checking the appropriate box. If your reason is listed as 'other,' please provide a detailed explanation in the space provided.
6. Complete the fields for the date of request, requestor name, and requestor phone number. Accurate contact information is necessary for communication.
7. If the original claim requires corrections, follow the 'Corrected Claim' process as stated in the Provider Manual, and do not submit the dispute form with the correction.
8. Mail the completed form along with any attachments, including a copy of the Explanation of Payment (EOP), to Ambetter from Buckeye Community Health Plan at the specified address.
9. Once the form is completed and mailed, keep a copy for your records. You may also choose to save it digitally for future reference.

Complete your PROVIDER CLAIM DISPUTE FORM online today to ensure a smooth dispute process.