Get Non-contracted Provider Payment Dispute Bformb - Triple-s Advantage

This guide provides clear, step-by-step instructions on how to effectively fill out the Non-Contracted Provider Payment Dispute Form for Triple-S Advantage online. By following these steps, users can easily submit their payment disputes and ensure all necessary information is included.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to access the form and open it in your preferred digital format.
2. Fill in the provider information section with details such as the physician's name, facility, Medicare ID, rendering provider NPI, and billing provider NPI.
3. Provide the member's name, member ID, and claim number related to the payment dispute.
4. Enter your contact information, including your name, telephone number, and fax number.
5. Record details such as the CPT/HCPCS codes, date of service, prior payment, and estimated amount due.
6. Clearly state the reason for the dispute in the designated section.
7. Compile all required documentation to submit with the form, which includes: a completed Form 1500/UB04, a copy of the Explanation of Payment, your contact information, pricing details with NPI number and ZIP code, any supporting documents, and a copy of the submitted claims indicating the disputed amount.
8. Review all sections to ensure all necessary information has been filled out accurately.
9. Once completed, you may save changes, download the form, print it, or share it as necessary for submission.

Start filling out your Non-Contracted Provider Payment Dispute Form online today!