Get Preferred Care Partners Claim Payment Dispute Request Form

Filling out the Preferred Care Partners Claim Payment Dispute Request Form online is an important step for non-contracted Medicare providers seeking to dispute claim payment issues. This guide will take you through each section of the form, ensuring you complete it accurately and efficiently.

Follow the steps to fill out the claim payment dispute form correctly.

1. Use the 'Get Form' button to access the Preferred Care Partners Claim Payment Dispute Request Form and open it in your editor.
2. Indicate your professional title by selecting an option: Physician, Hospital, or Other healthcare professional. This helps clarify your role in the dispute process.
3. Provide the member's details by entering their Member ID and Member Name. This identifies the individual whose claim you are disputing.
4. Input the Claim Number related to the dispute, along with the date of service for the claim in question. This information is critical for processing.
5. Enter your Provider/Facility Name and Street Address. Ensure that this information matches your official records to avoid delays.
6. Designate a Contact Person and indicate their Phone Number. This is the individual who will be reachable for any questions regarding the dispute.
7. Complete the Date Form Completed field. This is your acknowledgment that you are submitting the request as of today’s date.
8. In the Physician/health care professional information section, provide your Provider Name as listed on your Explanation of Payment (EOP) document.
9. Select the reason for your request from the provided list, which includes bundling issues, disputed rate of payment, DRG payment disputes, and other. Use the Comments section to elaborate on the reasons if necessary.
10. Attach all required documentation that supports your dispute. This includes a statement indicating the basis of the dispute, the original claim, the provider remittance notice, and any additional clinical records.
11. Clearly state what you are expecting from Preferred Care Partners to resolve the dispute, including any specific dollar amounts, if applicable.
12. Review your completed form for accuracy and completeness, then proceed to save changes, download, print, or share the form as needed.

Take the next step and complete your Preferred Care Partners Claim Payment Dispute Request Form online today.