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This guide provides clear and supportive instructions for filling out the Medical Fee Dispute Resolution Findings and Decision form from the Texas Department of Insurance. Users will find step-by-step guidance to help navigate the form effectively.

Follow the steps to complete your Medical Fee Dispute Resolution online.

1. Click ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Enter the requestor name and address in the designated field. For example, fill in 'C M Schade MD PhD, 2692 W Walnut Street Suite 105, Garland, TX 75042'.
3. Fill out the respondent name section with required details, such as 'Hopkins County Memorial Hospital, Carrier’s Austin Representative Box, Box Number 01'.
4. Input the MFDR tracking number in the appropriate area, referencing the specific case assigned, such as 'M4-08-1250-01'.
5. In the requestor’s position summary section, clearly articulate the reason for the dispute. Ensure it aligns with the provided medical necessity guidelines.
6. Indicate the amount in dispute, ensuring to double-check any financial figures for accuracy, such as '$12,443.31'.
7. Provide the respondent’s position summary in a similar, clear manner. Include key points of contention regarding medical necessity, documentation, and authorization.
8. Complete any additional required fields, summarizing findings relevant to your case, as instructed within the provided format.
9. Once all fields are completed, review the form thoroughly to ensure accuracy and compliance with guidelines.
10. Finally, save your changes, and choose to download, print, or share the completed form as needed.

Start filling out your Medical Fee Dispute Resolution form online today for a smooth submission process.