Get Ca Sharp Health Plan Provider Dispute Resolution Request 2022-2025

Filing a Provider Dispute Resolution Request can be a straightforward process when you know how to complete the form effectively. This guide is designed to assist you in filling out the CA Sharp Health Plan Provider Dispute Resolution Request online, ensuring that all necessary information is accurately provided.

Follow the steps to fill out the form online.

1. Click the ‘Get Form’ button to access the Provider Dispute Resolution Request form and open it in your preferred editor.
2. Begin by entering your Provider NPI number and Provider Name in the specified fields. These fields are mandatory, so ensure accurate entries.
3. Next, provide the Provider Tax ID and Provider Address, filling in the relevant sections. Select the appropriate Provider Type from the list provided.
4. For claim information, indicate whether the dispute concerns a single claim or multiple claims. Correspondingly, fill out the Claim categories as required.
5. Complete the patient’s information, including the Patient Name, Date of Birth, Health Plan ID Number, and Patient Account Number. Ensure that you accurately supply information relevant to the dispute.
6. Indicate the Original Claim ID Number, Original Claim Amount Billed, and Original Claim Amount Paid in the provided fields.
7. Select the appropriate Dispute Type based on the nature of your claim - whether it is a claim dispute, appeal of medical necessity decision, or other types as listed.
8. Use the DESCRIPTION OF DISPUTE field to clearly articulate the issues, followed by specifying the EXPECTED OUTCOME of your request.
9. Fill in your Contact Name, Title, Phone Number, and Signature in the designated areas, and date the form appropriately.
10. Once all fields are completed, review the data for accuracy. You can then save changes, download, print, or share the form as needed.

Take action today and complete your Provider Dispute Resolution Request online.