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.
| Question | Answer |
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| Form Name | Provider Dispute Resolution Request |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names |
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
∙Mail the completed form to: AHCIPA
P.O. Box 570280
Tarzana, CA 91357
*PROVIDER NPI: |
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PROVIDER TAX ID: |
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*PROVIDER NAME: |
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PROVIDER ADDRESS: |
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PROVIDER TYPE |
MD |
Mental Health Professional |
Mental Health Institutional |
Hospital |
ASC |
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SNF |
DME |
Rehab |
Home Health |
Ambulance |
Other ____________________________ |
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(please specify type of “other”) |
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CLAIM INFORMATION |
Single |
Multiple “LIKE” Claims (complete attached spreadsheet) |
Number of claims:___ |
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* Patient Name: |
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Date of Birth: |
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*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
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Fax Number |
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For Health Plan/RBO Use Only
TRACKING NUMBER ________________________ PROV ID# __________
CONTRACTED _____
PROVIDER DISPUTE RESOLUTION REQUEST
For use with multiple “LIKE” claims (claims disputed for the same reason)
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*Patient Name
Last |
First |
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Date of
Birth
*Health Plan ID Number
Original Claim ID Number
* Service From/To |
Original Claim |
Date |
Amount Billed |
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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,
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: |
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PROVIDER ID or NPI#: |
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a. PROVIDER NAME: |
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b. CONTRACTED PROVIDER: |
_____ YES _____ NO |
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c. DATE DISPUTE RECEIVED (Date Stamped): |
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d. DATE OF INITIAL PAYMENT OR ACTION: |
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e. WAS DISPUTE RECEIVED WITHIN TIMEFRAME? |
(c |
– d) |
_____YES |
_____ NO |
(If NO, should be returned |
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to provider without action) |
f.1. DISPUTE TYPE: |
CLAIM |
APPEAL OF MEDICAL NECESSITY/UM DECISION |
BILLING DETERMINATION |
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OVERPAYMENT DISPUTE |
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CONTRACT DISPUTE |
OTHER _______________________________ |
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(Please specify type of “other”) |
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f.2. PROVIDER TYPE: |
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PROFESSIONAL |
INSTITUTIONAL |
OTHER |
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g. DATE DISPUTE ACKNOWLEDGED: |
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h. TURNAROUND TIME (g – c): |
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TYPE OF LETTER SENT: |
(List the various ICE letters as applicable) |
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IF NO ADDITIONAL INFORMATION REQUESTED: |
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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