Get Cob Dispute & Adjustment Request Form - Buckeye Community ...

The COB Dispute & Adjustment Request Form is a vital document for users wishing to request a review of a claim payment or recovery. This guide provides clear, step-by-step instructions on how to effectively fill out this form online, ensuring that all necessary information is accurately provided.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the COB Dispute & Adjustment Request Form and open it in your preferred PDF editor.
2. Begin by completing the required information in the designated box. This includes: the date of your request, provider name, provider number, claim number, member name, and member number. Ensure accuracy in these fields as they are crucial for your request.
3. In the dispute section, provide supporting documentation as required. This may include the primary carrier’s EOP or any correspondence that informs you about coverage status. Additionally, detail your efforts in contacting the member or primary carrier and offer a comprehensive explanation of the issue you are disputing.
4. If you are resubmitting claims to Buckeye as the secondary carrier, include the primary carrier’s EOP along with the explanation pages. Attach the corrected claim that illustrates the payment made by the primary carrier.
5. Once you have filled out the form and attached all necessary documentation, review your information for completeness and accuracy to prevent any delays.
6. Mail the completed form and attachments to Buckeye Community Health Plan at the provided address: P.O. Box 6200, Farmington, MO 63640-3805. A photocopy of the form is acceptable if needed.

Take action now and complete your COB Dispute & Adjustment Request Form online to ensure timely processing.