Get Section 1011 Dispute Resolution Request - Centers For ... - Cms

Filing a SECTION 1011 dispute resolution request is an important step for users seeking redress regarding payment determinations. This guide will provide clear instructions on how to complete and submit the form effectively, ensuring that all necessary information is accurately provided to avoid dismissal of the request.

Follow the steps to successfully complete the dispute resolution request.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the provider name in the designated field. Ensure that this matches the official documentation for consistency.
3. Input the SECTION 1011 provider identification number (PIN) accurately, as this is crucial for processing your request.
4. Provide the patient identifier number (HIC) to identify the individual involved in the dispute.
5. Enter the document control number (DCN) related to the payment request.
6. Specify the full date range of service associated with the disputed item to give context to your request.
7. Detail the specific dates of items in dispute to pinpoint the exact instances being contested.
8. Outline the original amount submitted for reimbursement next to the appropriate label.
9. Clearly describe the denied service and include the reason for the dispute to support your request.
10. Fill in the requester's name and title, ensuring correct spelling and relevant designation.
11. Provide the requester's e-mail address for communication about the dispute.
12. Enter the complete mailing address, including city, state, and zip code, to ensure proper correspondence.
13. Include the requester's telephone number, ensuring to include the area code for accuracy.
14. The requester must sign and date the form to validate the request. This is a mandatory step for processing.
15. Indicate whether all documentation regarding the dispute is attached. If applicable, check the box next to 'Letter of representation is attached'.
16. Review all sections carefully for completeness, as failure to complete all data elements may result in dismissal of your request.
17. Once all fields are filled out correctly, save your changes, and prepare your documentation for mailing.

Complete your SECTION 1011 DISpute RESOLuTION REquEST online to ensure a smooth submission process.