Provider Dispute Resolution Request PDF 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 Length2 pages
Fillable?Yes
Fillable fields134
Avg. time to fill out27 min 22 sec
Other names medpoint accountable form

Form Preview Example

PROVIDER DISPUTE RESOLUTION REQUEST

NOTE: SUBMISSION OF THIS FORM CONSTITUTES AGREEMENT NOT TO BILL THE PATIENT

DURING THE DISPUTE RESOLUTION PROCESS.

INSTRUCTIONS

Please complete the below form. Fields with an asterisk ( * ) are required. For the online editable form, use the tab key to move from field to field. Use the spacebar to check the appropriate boxes.

Please complete this form if you are seeking reconsideration of a previous billing determination.

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.

In order to ensure the integrity of the Provider Dispute Resolution (PDR) process, we will re-categorize issues sent to us on a PDR form which are not true provider disputes (e.g., claims check tracers or a provider's submission of medical records after payment was denied due to a lack of documentation).

For routine follow-up, please use the Claims Follow-Up Form.

• Mail the completed form to:

Anthem Blue Cross

 

P.O. Box 60007

 

Los Angeles, CA 90060-0007

 

 

 

*PROVIDER NAME:

 

*PROVIDER NPI #:

PROVIDER ADDRESS:

 

 

 

 

 

PROVIDER TYPE

MD

Mental Health

Hospital

ASC

SNF

DME

Home Health

Ambulance

Other

(please specify type of “other”)

 

 

 

 

Rehab

* CLAIM INFORMATION

Single

Substantially Similar Multiple Claims (complete attached spreadsheet)

 

 

 

Date of Birth:

* Patient Name:

 

 

 

 

 

 

*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

Seeking Resolution Of A Previous Billing Determination

Appeal of Medical Necessity / Utilization Management Decision

Contract Dispute

Request For Reimbursement Of Overpayment

Other:

*DESCRIPTION OF DISPUTE:

EXPECTED OUTCOME:

 

 

 

(

)

 

Contact Name (please print)

 

Title

 

 

 

 

Phone Number

 

 

 

 

(

)

 

Signature

 

Date

 

 

 

Fax Number

 

[ ] CHECK HERE IF ADDITIONAL INFORMATION IS ATTACHED

 

 

For Health Plan Use Only

 

(Please do not staple additional information)

 

 

TRACKING NUMBER

 

 

 

 

 

PROVIDER ID#

 

 

 

 

 

 

 

 

 

 

 

 

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.

®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Revised December 2009

PROVIDER DISPUTE RESOLUTION REQUEST

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

*PROVIDER NAME:

*PROVIDER NPI #:

 

 

* Patient Name

 

 

 

 

 

 

 

 

* Service

 

Original

 

Original

 

 

 

 

 

 

 

 

* Health Plan ID

 

 

 

 

Claim

 

 

 

 

 

 

 

 

 

Date of

 

 

Original Claim ID

 

From/To

 

Amount

 

Claim

 

 

Number

 

Last

First

 

 

Birth

 

Number

 

Number

 

Date

 

Billed

 

Amount Paid

 

Expected Outcome

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

[ ] CHECK HERE IF ADDITIONAL INFORMATION IS ATTACHED (Please do not staple additional information)

Page ______ of ______

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.

®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Revised April 2009

How to Edit Provider Dispute Resolution Request Online for Free

The PDF editor will make creating files easy. It is quite effortless manage the Provider Dispute Resolution Request form. Follow the next steps if you want to achieve this:

Step 1: You should click the orange "Get Form Now" button at the top of the following page.

Step 2: Now you're on the form editing page. You may modify and add information to the form, highlight words and phrases, cross or check specific words, add images, insert a signature on it, delete unneeded fields, or remove them completely.

Get the Provider Dispute Resolution Request PDF and enter the details for each segment:

step 1 to filling in Provider Dispute Resolution Request

You have to write down the crucial data in the DESCRIPTION, OF, DISPUTE EXPECTED, OUTCOME Title, Date Phone, Number, Fax, Number For, Health, Plan, Use, Only TRACKING, NUMBER, PROVIDE, RID and Revised, December space.

Filling in Provider Dispute Resolution Request part 2

Jot down the necessary data in PROVIDER, NAME PROVIDER, NP, I Patient, Name, First, Last DateofBirth, Health, Plan, ID Number, Original, Claim, ID Number, Service, From, To Date, Number, Original, Claim, Amount, Billed Original, Claim Amount, Paid and Expected, Outcome part.

Provider Dispute Resolution Request PROVIDERNAME, PROVIDERNPI, PatientNameFirstLast, DateofBirth, HealthPlanID, Number, OriginalClaimID, Number, ServiceFromTo, Date, Number, OriginalClaimAmountBilled, OriginalClaim, AmountPaid, and ExpectedOutcome blanks to fill out

The Page, of and Revised, April field needs to be applied to put down the rights or obligations of both parties.

Completing Provider Dispute Resolution Request step 4

Step 3: Choose "Done". Now you may export the PDF document.

Step 4: Generate duplicates of your document. This would prevent forthcoming misunderstandings. We don't read or disclose the information you have, thus be sure it will be safe.

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