Ensuring Details

Are you having a dispute with your healthcare provider? If so, the Provider Dispute Resolution Request Form can help. This form is used to request mediation or arbitration of a dispute with a health care provider. It provides a process for resolving disputes without going to court. The form can be used by individuals or groups of people who have been denied benefits, had services cancelled, or received an incorrect bill. Using the form can help you resolve your dispute without hiring a lawyer.

You could find it useful to know the amount of time you'll need to fill out this provider dispute resolution request and how long this document is.

QuestionAnswer
Form NameProvider Dispute Resolution Request
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other names

Form Preview Example

PROVIDER DISPUTE RESOLUTION REQUEST

INSTRUCTIONS

Please complete the below form. Fields with an asterisk ( * ) are required.

Be specific when completing the DESCRIPTION OF DISPUTE and EXPECTED OUTCOME.

Provide additional information to support the description of the dispute. Do not include a copy of a claim that was previously processed.

Multiple “LIKE” claims are for the same provider and dispute but different members and dates of service.

For routine follow-up, please use the Claims Follow-Up Form instead of the Provider Dispute Resolution Form.

Mail the completed form to: AHCIPA

P.O. Box 570280

Tarzana, CA 91357

*PROVIDER NPI:

 

 

PROVIDER TAX ID:

 

 

*PROVIDER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER TYPE

MD

Mental Health Professional

Mental Health Institutional

Hospital

ASC

SNF

DME

Rehab

Home Health

Ambulance

Other ____________________________

 

 

 

 

 

 

 

(please specify type of “other”)

 

CLAIM INFORMATION

Single

Multiple “LIKE” Claims (complete attached spreadsheet)

Number of claims:___

 

 

 

 

 

 

 

 

 

 

* Patient Name:

 

 

 

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

*Health Plan ID Number:

Patient Account Number:

Original Claim ID Number: (If multiple claims, use

attached spreadsheet)

Service “From/To” Date: ( * Required for Claim, Billing, and Reimbursement Of Overpayment Disputes)

Original Claim Amount Billed: Original Claim Amount Paid:

DISPUTE TYPE

Claim

Appeal of Medical Necessity / Utilization Management Decision

Disputing Request For Reimbursement Of Overpayment

Seeking Resolution Of A Billing Determination Contract Dispute

Other:

*DESCRIPTION OF DISPUTE:

EXPECTED OUTCOME:

Contact Name (please print)

Signature

[] CHECK HERE IF ADDITIONAL

INFORMATION IS ATTACHED

(Please do not staple)

ICE Approved 10/5/07, effective 1/1/08

Title

 

Phone Number

 

(

)

Date

 

Fax Number

For Health Plan/RBO Use Only

TRACKING NUMBER ________________________ PROV ID# __________

CONTRACTED _____ NON-CONTRACTED _____

PROVIDER DISPUTE RESOLUTION REQUEST

For use with multiple “LIKE” claims (claims disputed for the same reason)

1

2

3

4

5

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*Patient Name

Last

First

 

 

Date of

Birth

*Health Plan ID Number

Original Claim ID Number

* Service From/To

Original Claim

Date

Amount Billed

 

 

Original Claim Amount Paid

Page ______ of ______

[] CHECK HERE IF ADDITIONAL

INFORMATION IS ATTACHED

(Please do not staple)

ICE Approved 10/5/07, effective 1/1/08

PROVIDER DISPUTE RESOLUTION REQUEST

Tracking Form

(For Optional Use by Health Plan/Delegated Provider)

INSTRUCTIONS

This optional form may be used to track the status, time-frames and disposition of the Provider Dispute Resolution.

The entity processing the Provider Dispute Resolution should track the following information internally for ensuring compliance with regulations and for later reporting to the appropriate entity.

TRACKING NUMBER:

 

 

 

 

 

PROVIDER ID or NPI#:

 

 

 

 

 

 

 

 

 

a. PROVIDER NAME:

 

 

 

 

 

b. CONTRACTED PROVIDER:

_____ YES _____ NO

 

 

 

 

c. DATE DISPUTE RECEIVED (Date Stamped):

 

 

d. DATE OF INITIAL PAYMENT OR ACTION:

 

 

 

 

 

 

e. WAS DISPUTE RECEIVED WITHIN TIMEFRAME?

(c

– d)

_____YES

_____ NO

(If NO, should be returned

 

 

 

 

 

 

 

 

 

to provider without action)

f.1. DISPUTE TYPE:

CLAIM

APPEAL OF MEDICAL NECESSITY/UM DECISION

BILLING DETERMINATION

OVERPAYMENT DISPUTE

 

CONTRACT DISPUTE

OTHER _______________________________

 

 

 

 

 

 

 

 

(Please specify type of “other”)

 

 

 

 

 

 

 

 

f.2. PROVIDER TYPE:

 

PROFESSIONAL

INSTITUTIONAL

OTHER

 

 

 

 

 

g. DATE DISPUTE ACKNOWLEDGED:

 

 

h. TURNAROUND TIME (g – c):

 

 

 

 

 

 

TYPE OF LETTER SENT:

(List the various ICE letters as applicable)

 

 

IF NO ADDITIONAL INFORMATION REQUESTED:

 

 

 

 

 

 

j. DATE OF ACTION:

k.ACTION TURNAROUND TIME (j – c):

l.TYPE OF ACTION

UPHELD

OVERTURNED

OTHER

IF ADDITIONAL INFORMATION REQUESTED:

m. DATE ADDITIONAL INFO REQUESTED:

n. TURNAROUND TIME (m – c):

o. DATE ADDITIONAL INFO RECEIVED:

p. RECEIPT TURNAROUND TIME (o – m):

q. DATE OF ACTION:

r.ACTION TURNAROUND TIME (q – o):

s.TYPE OF ACTION

UPHELD

OVERTURNED

OTHER

ACTIONCOMPLETE(If decidedDESCRIPTIONin wholeOForDETERMINATIONpart on behalf of provider,RATIONALE:apply appropriate interest to payment or partial payment and make payment within 5 days of issuing determination):

ICE Approved 10/5/07, effective 1/1/08