Get Kaiser Permanente Provider Payment Dispute Resolution Submission Form 2018-2025

This guide provides a detailed walkthrough on how to successfully complete the Kaiser Permanente Provider Payment Dispute Resolution Submission Form online. It is designed to assist users in filling out all required fields accurately and efficiently.

Follow the steps to complete your submission form effectively.

1. Press the ‘Get Form’ button to obtain the Kaiser Permanente Provider Payment Dispute Resolution Submission Form and open it in your editor.
2. Fill in the provider tax identification number in the designated field to ensure proper identification of the provider for the dispute.
3. Enter the provider group name and address to clearly specify the entity involved in the dispute.
4. Input the provider contact name and their phone number for any follow-up regarding the dispute.
5. Provide the provider's email address, which will be used for communication about the dispute.
6. Record the date of completion to maintain accurate records of your submission.
7. Select the applicable box under the administrative or reimbursement denials that corresponds to your dispute. Make sure to choose the specific reason for the denial.
8. Provide information about the member involved by entering their name and their medical record number (MRN).
9. State the total billed amount in question to clarify the financial aspect of the dispute.
10. Include the claim number(s) associated with the dispute to assist in the retrieval of relevant records.
11. Compile all additional documentation required, such as the detailed appeal letter and any relevant medical records.
12. Once you have filled out all sections, review the form for accuracy and completeness. Save your changes, then download, print, or share the completed form as necessary.

Complete your Kaiser Permanente Provider Payment Dispute Resolution Submission Form online today.