Get Multiple Like Claims Are For The Same Provider And Dispute But Different Members And Dates Of

Filling out the Multiple LIKE Claims Are For The Same Provider And Dispute But Different Members And Dates Of form can seem daunting, but with clear guidance, you can efficiently complete the process. This document assists providers in disputing multiple claims concerning the same issues and helps ensure that all necessary information is submitted accurately.

Follow the steps to effectively complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Start by filling in the required fields marked with an asterisk (*), such as the provider's NPI, name, and health plan ID number. Ensure that you fill these fields accurately to avoid any delays.
3. In the claim information section, specify if you are submitting single or multiple LIKE claims. If multiple, complete the attached spreadsheet accordingly.
4. Fill in the dates of service in the 'Service From/To' field and include the original claim amounts billed and paid.
5. Indicate the type of dispute you are submitting by selecting from the options provided, such as billing determination or contract dispute.
6. In the 'Description of Dispute' field, articulate the specifics of your dispute. Be clear and provide any supportive information to enhance your claim.
7. State your expected outcome in the designated field to clarify the resolution you seek from this dispute.
8. Complete the contact details section, including your name, title, and phone number for any follow-ups.
9. Once all fields are filled, review the document for accuracy. Ensure you have included all necessary attachments if indicated.
10. Finally, save any changes made to the form, and you can choose to download, print, or share the form as required.

Take the next step in your claims process by completing and submitting your document online today.