Get Allwell - Provider Request For Reconsideration And Claim Dispute Form. Provider Request For

Completing the Allwell - Provider Request For Reconsideration And Claim Dispute Form is essential for providers seeking to address disagreements regarding claims processing. This guide will walk you through each section of the form to ensure you fill it out accurately and efficiently.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill in the required fields with accurate information. Start with the Provider Name and Provider Tax ID #. Ensure that both are correctly entered as they are crucial for identifying your practice.
3. Input the Control/Claim Number related to the dispute. This number helps to track the claim in question.
4. Specify the Date(s) of Service. Enter the appropriate dates accurately to avoid any processing delays.
5. Complete the Member Name and Member (RID) Number fields with the respective details of the member involved in the claim.
6. Indicate the level of dispute by checking the appropriate box for either Level I - Request for Reconsideration or Level II – Claim Dispute. If filing Level I, attach relevant medical records as instructed.
7. Select the reason for your dispute. Check all applicable reasons and provide any necessary additional information, particularly when mentioning authorization numbers or attaching proofs.
8. Enter the Requestor Name, Requestor Phone Number, and Date of Request. This information should belong to the person handling this appeal.
9. Review all entries for accuracy. Ensure that no fields are left incomplete, as all information is required.
10. Once complete, you can save changes and download or print the form. Finally, mail the finished form along with any necessary attachments to the appropriate address based on the level of dispute.

Complete your document submissions online to streamline the reconsideration and dispute process.