Get Provider Dispute Resolution Request Form - Universal

This guide is designed to assist you in completing the Provider Dispute Resolution Request Form - Universal online. By following these steps, you can ensure that your form is filled out accurately and efficiently, facilitating the dispute resolution process.

Follow the steps to complete your form with ease.

1. To begin, press the ‘Get Form’ button to acquire the form and open it in your preferred editor.
2. In the first section, enter the provider's name and address accurately. This is important as it identifies the party involved in the dispute.
3. Next, select the provider type from the options available, including options such as MD, DME, Mental Hospital, Hospital, etc. Be sure to specify any unique types if applicable.
4. In the 'Claim Information' section, fill in the required patient name and health plan ID number. Ensure that the health plan ID number is correct to avoid processing delays.
5. Provide the service from/to dates. Documenting this accurately is crucial for the claims being disputed.
6. Include the provider tax ID number or Medicare ID number in the designated field, as this may affect the resolution process.
7. If applicable, note multiple claims by indicating the number of claims and providing a separate listing as needed.
8. Fill in the patient account number and date of birth, ensuring that the information matches the records of the claim.
9. Specify the original claim ID number and the original claim amount billed in the respective sections.
10. Indicate the dispute type that best represents your situation, such as a claim dispute, appeal of medical necessity, or another relevant option.
11. In the 'Description of Dispute' field, provide a detailed account of your dispute, followed by the expected outcome. Be as specific and concise as possible.
12. List the contact name and title for follow-up communication. Make sure to include a phone number for any needed clarifications.
13. If you are including additional information, check the box indicating that supplementary documents are attached.
14. Finally, review all entries for accuracy. Once completed, you can save changes, download, print, or share the form as necessary.

Complete your Provider Dispute Resolution Request Form online today to initiate your dispute process.