Get Pr Triple-s Advantage Non-contracted Provider Payment Dispute Form 2021-2025

Filing a payment dispute can be an important step in resolving discrepancies related to claims. This guide will walk you through the process of completing the PR Triple-S Advantage Non-Contracted Provider Payment Dispute Form online, ensuring you understand each component and its requirements.

Follow the steps to complete your payment dispute form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the provider information section. Include the physician's name, facility name, Medicare ID, and relevant NPI numbers for both the rendering and billing providers.
3. Complete the member information with the member's name, ID, and claim number.
4. Provide your contact details in the designated fields, including your telephone number and fax number.
5. Fill in the CPT/HCPCs codes, date of service, and the amount due.
6. Clearly state the reason for the dispute in the specified field.
7. Prepare the required documentation to submit along with the form. This includes Form 1500/UB04, a copy of the Explanation of Payment, provider contact information, pricing information, and any supporting documents that justify the payment dispute.
8. Once you have completed the form and gathered the necessary documentation, review everything for accuracy.
9. Finalize by saving your changes, and then choose to download, print, or share the completed form as needed.

Start completing your PR Triple-S Advantage Non-Contracted Provider Payment Dispute Form online today to ensure timely resolution of your payment issues.