Get Provider Dispute Resolution Request Instructions - Brand New Day

Filling out the Provider Dispute Resolution Request is a crucial step in resolving disputes effectively. This guide will provide you with comprehensive instructions to ensure you complete the form accurately and efficiently, catering to users regardless of their legal experience.

Follow the steps to complete your Provider Dispute Resolution Request form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the provider name, ensuring that all required fields, designated by an asterisk (*), are completed for proper identification.
3. Enter the provider tax ID number or Medicare ID number. This is crucial for accurate processing.
4. Complete the provider address section. This helps to establish the location from which the dispute is submitted.
5. Select the provider type from the given options such as MD, hospital, or other. If you select 'Other,' please specify the type.
6. Fill in the claim information, indicating whether it's for single or multiple claims. If handling multiple claims, complete the attached spreadsheet.
7. Provide the patient’s name and Health Plan ID number. The date of birth and patient account number are also required, ensuring accurate identification of the patient.
8. Include the original claim ID number. If submitting multiple claims, refer to the attached spreadsheet for accuracy.
9. Specify the service 'From/To' date, which is required for certain types of disputes.
10. Document the original claim amount billed and the amount paid to provide context for your dispute.
11. Indicate the type of dispute you are filing, selecting from the options provided such as claim, appeal of medical necessity, or contract dispute.
12. Write a clear and specific description of the dispute. Include any additional information that supports your request for resolution.
13. Articulate the expected outcome of your dispute, detailing what resolution you seek.
14. Complete the contact name, title, and phone number section to ensure you can be reached for follow-up.
15. Sign and date the form. This serves as confirmation of your request and agreement not to bill the patient.
16. Finally, provide your fax number if applicable. After completing the form, save your changes, download, print, or share the form as needed.

Take the next step in resolving your disputes by completing the Provider Dispute Resolution Request online today.