Get Use This Form As Part Of The Ambetter From Mhs Claim Dispute Process To Dispute The Decision Made

The Use This Form As Part Of The Ambetter From MHS Claim Dispute Process To Dispute The Decision Made is a key document for providers wishing to contest decisions made by Ambetter from MHS. This guide will walk you through the steps necessary to successfully complete and submit the form online.

Follow the steps to fill out the form correctly and efficiently.

1. Click the ‘Get Form’ button to obtain the form and open it in the document editor.
2. Begin by entering the provider's name in the designated field. This identifies the healthcare provider who is disputing the claim.
3. Fill in the member's name who is associated with the claim. Accurate identification of individuals is crucial for the dispute process.
4. Input the provider's Tax Identification Number (Tax ID#) in the corresponding field.
5. Enter the member's RID number, which is essential for locating the claim within the system.
6. Complete the requestor's name and title. This identifies who is submitting the dispute on behalf of the provider.
7. Specify the date of the request in the provided section.
8. Include the requestor's phone number, ensuring you can be reached if additional information is needed.
9. List the claim number(s) related to the dispute to help in tracking the request.
10. Fill in the date(s) of service, which is important for validating the claim information.
11. Select the reason for the dispute by checking the appropriate box. Providing clear reasons for your dispute allows for effective review.
12. If the original claim submitted requires correction, note that a corrected claim must follow the guidelines in the Ambetter Provider Manual, without including this form.
13. Once completed, print and attach any required documents, including a copy of the Explanation of Payment(s) with the claims clearly indicated.
14. Mail the completed form and attachments to Ambetter from MHS at the specified address, ensuring you retain copies for your records.
15. After submission, you can monitor the resolution process, which typically takes 30 days for electronic submissions and 45 days for paper submissions. Expect either a notice of reprocessing or an explanation if reprocessing is not appropriate.

Complete and submit your documents online to ensure a smooth claim dispute process.