Get Mdwise Dispute Form

Filling out the Mdwise Dispute Form online can seem challenging, but with the right guidance, you can navigate it easily. This guide will walk you through each section of the form to ensure that all necessary information is provided accurately.

Follow the steps to complete the Mdwise Dispute Form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the facility or provider name in the designated field.
3. Input the date of filling out the form.
4. Provide a telephone number where you can be reached.
5. Enter your email address for correspondence.
6. Fill in the member's name associated with the claim.
7. Provide the member's date of birth.
8. Specify the date of service related to the claim.
9. Input the member ID number accurately.
10. Enter the billed amount for the service being disputed.
11. Provide the claim number.
12. Select the level of dispute: 1st level or 2nd level.
13. Choose the applicable MDwise program: Hoosier Healthwise, HIP, MDwise Marketplace, or Hoosier Care Connect.
14. Clearly state the reason for the claim dispute in the designated area.
15. Describe the disputed claim, including the reason for denial and your position statement why the claim should be paid.
16. Attach any relevant documentation, such as the explanation of payment or denial letter.
17. In the 'Form Completed By' section, print your name.
18. Include the date on which the form is completed.
19. Submit the completed form to MDwise at the address provided, and ensure you have a correspondence address ready.

Complete your Mdwise Dispute Form online today to resolve your claims efficiently.