Get Billing Dispute Resolution Request Form - Palmetto Gba

Filling out the Billing Dispute Resolution Request Form is an essential step in addressing any billing issues with Palmetto GBA. This guide provides clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete the form accurately

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Provide your provider information in the designated fields: input your provider name, provider number, NPI, TIN, contact person's name, and contact number.
3. Fill out the patient or beneficiary information section with the patient's first and last name, HIC number, and date of birth.
4. Complete the claim information by entering the dates of service. Specify the range by filling in the from and through dates, and list any DCNs applicable to the claim.
5. In the contact resolution information section, document the name of the agency contacted, the method of contact used (phone, letter, fax, or other), and the date the agency was contacted.
6. Indicate the individual's name you spoke with and answer whether the agency is out of business. If applicable, provide an explanation.
7. Identify the situation that pertains to your billing dispute, such as billing overlap or sequential billing, and include any required documentation mentioned in the form.
8. Utilize the additional comments section for any further information relevant to your dispute.
9. Review your entries for accuracy, then save, download, print, or share the completed form as needed.

Take action now by completing the Billing Dispute Resolution Request Form online to address your billing concerns.