Get Provider Payment Dispute Form - Healthspan - Healthspan

Filing a Provider Payment Dispute Form with HealthSpan can be a straightforward process if you follow the right steps. This guide will provide you with clear instructions to help you complete the form correctly and efficiently.

Follow the steps to fill out the Provider Payment Dispute Form online.

1. Press the ‘Get Form’ button to obtain the Provider Payment Dispute Form and open it for completion.
2. Begin by filling out the 'Provider Information' section. Include the submission date, your name or contact name, contact telephone number, nine-digit tax ID number, provider name, mailing address (including city, state, and zip code), and provider’s fax number. Indicate whether you are a contracted provider with HealthSpan by checking the appropriate box.
3. Next, move to the 'Patient Information' section. Enter the healthSpan medical record number (MRN), patient name, date of birth, healthSpan claim document number, date of service, and denial reason codes from the Explanation of Payment.
4. In the 'Type of Denial' section, select the relevant denials by checking the appropriate boxes. You may also be required to provide any pricing specifications or other relevant information regarding the denial.
5. Provide the rationale for your request in the space provided. Be as detailed as possible to support your dispute.
6. If necessary, attach any supporting documents that may be required for your dispute.
7. Finally, review all the information you have entered for accuracy. Once you have confirmed that everything is correct, you can save your changes, download, print, or share the completed form as needed.

Complete your Provider Payment Dispute Form online today to ensure a timely resolution.