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Attach supporting documentation. Check here if additional information is attached. Authorized Representative Name please print Title Date Health Plan use only Florida Hospital Care Advantage is administered by Health First Health Plans Revised December 24 2014. Provider Claim Dispute Request INSTRUCTIONS Return this form within 6 months from the date of service in dispute. Use one form for each disputed claim* Provide a clear rationale and any additional documentation such as medical records to support your claim* Allow 30 days to elapse before checking the status of your dispute. Mail or fax this form to Health First Health Plans Fax 321 434-4228 Claims Resolution Unit 6450 US Highway 1 Rockledge FL 32955 Your dispute will be resolved within 60 days of receiving this form* If the decision is in your favor you will receive a corrected payment and a new Remittance Advice. PROVIDER INFORMATION Provider Name Phone Number Billing Address Member ID Date of Birth Amount Paid Claim and Procedure Code PATIENT INFORMATION Patient Name CLAIM INFORMATION Date of Service Amount Billed DISPUTE INFORMATION Denial Reason Additional information needed Authorization not obtained Benefit maximum exceeded Bundling/Unbundling Coding Coordination of benefits Duplicate claim Member eligibility Not contracted for service Pre-X exclusion Timely filing Payment Issue Contractual amount Under/Overpayment Member cost-share Describe your desired outcome and why you feel it is appropriate. Provider Claim Dispute Request INSTRUCTIONS Return this form within 6 months from the date of service in dispute. Use one form for each disputed claim* Provide a clear rationale and any additional documentation such as medical records to support your claim* Allow 30 days to elapse before checking the status of your dispute. Use one form for each disputed claim* Provide a clear rationale and any additional documentation such as medical records to support your claim* Allow 30 days to elapse before checking the status of your dispute. Mail or fax this form to Health First Health Plans Fax 321 434-4228 Claims Resolution Unit 6450 US Highway 1 Rockledge FL 32955 Your dispute will be resolved within 60 days of receiving this form* If the decision is in your favor you will receive a corrected payment and a new Remittance Advice. Mail or fax this form to Health First Health Plans Fax 321 434-4228 Claims Resolution Unit 6450 US Highway 1 Rockledge FL 32955 Your dispute will be resolved within 60 days of receiving this form* If the decision is in your favor you will receive a corrected payment and a new Remittance Advice. PROVIDER INFORMATION Provider Name Phone Number Billing Address Member ID Date of Birth Amount Paid Claim and Procedure Code PATIENT INFORMATION Patient Name CLAIM INFORMATION Date of Service Amount Billed DISPUTE INFORMATION Denial Reason Additional information needed Authorization not obtained Benefit maximum exceeded Bundling/Unbundling Coding Coordination of benefits Duplicate claim Member eligibility Not contracted for service Pre-X exclusion Timely filing Payment Issue Contractual amount Under/Overpayment Member cost-share Describe your desired outcome and why you feel it is appropriate..

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