Washington Self-Insurance Medical Provider Billing Dispute Form is a document used by medical providers in Washington State to dispute payments received from self-insured health plans. This form can be used to dispute payment amounts, denials, or other issues related to a provider's billing. There are two types of Washington Self-Insurance Medical Provider Billing Dispute Forms: • Standard Dispute For— – This form is used to dispute a payment amount, denial, or other issue related to a provider’s billing. This form must be completed in full and include supporting documents such as a copy of the claim and any explanation of benefits. • Expedited Dispute For— – This form is used to expedite the dispute process. It must be completed in full and include supporting documents such as a copy of the claim and any explanation of benefits. It must be submitted within 10 business days of receipt of the payment or denial.