Get Capcms

Filling out the Capcms form is an essential step in initiating a provider dispute resolution request. This guide offers a step-by-step approach to ensure users can confidently complete the form accurately and efficiently.

Follow the steps to successfully fill out the Capcms online form.

1. Click ‘Get Form’ button to access the Capcms form and open it in your preferred online editor.
2. Begin by filling in the required fields, starting with the provider NPI number and provider name. Ensure all information is accurate to avoid delays.
3. Complete the provider tax ID and address information. If applicable, specify the provider type by selecting the appropriate option from the list provided.
4. In the claim information section, indicate whether it is a single claim or multiple 'LIKE' claims. For multiple claims, you will need to complete an attached spreadsheet.
5. Fill in the required patient information, including the patient's name, date of birth, and health plan ID number. Be sure to use the exact format as indicated.
6. Provide details for the original claim, including the original claim ID number and service dates, which are mandatory for certain types of disputes.
7. Select the dispute type from the given options. Ensure you specify the original claim amount billed and paid.
8. In the description of the dispute section, provide a clear and specific explanation of your issue, and outline your expected outcome. This will help expedite the resolution process.
9. Enter contact details, including your name, title, and phone number. Don't forget to sign and date the form to authenticate it.
10. Review the form for completeness and accuracy. If you have additional information to attach, check the box indicating that and ensure you follow instructions regarding attachments.
11. Once you have completed the form, save your changes, and download a copy for your records. You can also print or share the form as needed.

Start filling out your Capcms form online today to expedite your dispute resolution process.