Get Claim Dispute Form - Illinicare

This guide will assist you in completing the Claim Dispute Form for Illinicare, ensuring all necessary information is provided accurately. Following these steps will facilitate your claim dispute process efficiently and effectively.

Follow the steps to expertly fill out your form.

1. Press the ‘Get Form’ button to access the Claim Dispute Form and open it in your chosen document editor.
2. Begin by entering the provider name in the designated field. This is the person or organization filing the dispute.
3. Input the control or claim number associated with your dispute in the appropriate field. This number is crucial for tracking your claim.
4. Fill in the member name, ensuring you accurately reflect the individual associated with the claim.
5. Enter the provider tax identification number (Tax ID) in the specified field. This number verifies your credentials as a provider.
6. Document the dates of service in the given area. This information clarifies the timeline of the services in question.
7. Include the member identification number (RID) in the designated section on the form.
8. Choose the reason for your dispute by checking the relevant box. This detail is essential for assessing your claim.
9. If you selected 'Other' as your reason, clearly explain your rationale in the space provided below.
10. Fill in the date of your request along with your name in the respective fields.
11. Provide your contact phone number, ensuring you can be reached for any questions regarding your dispute.
12. Attach a copy of the explanation of payment (EOP) documents that are relevant to the claim you are disputing, as well as any responses to your original reconsideration request.
13. Once you have completed all fields, review the form for accuracy, and make any necessary adjustments.
14. Save your changes, then download, print, or share the form as needed. Ensure you send the completed form and any attachments to the address provided.

Complete your Claim Dispute Form online today for a smoother resolution process.