Provider dispute resolution request form blank 2025

1. Click ‘Get Form’ to open the provider dispute resolution request form in the editor.
2. Begin by filling in your *PROVIDER NAME* and *PROVIDER TAX ID # / Medicare ID #*. These fields are mandatory, so ensure accuracy.
3. Complete the *PROVIDER ADDRESS* and select your *PROVIDER TYPE* from the options provided, such as MD, Mental Health, or Hospital.
4. In the *CLAIM INFORMATION* section, indicate whether you are submitting a single claim or multiple claims. If multiple, complete the attached spreadsheet.
5. Fill in the *Patient Name*, *Health Plan ID Number*, and other relevant details like Original Claim ID Number and Service Dates as required.
6. Clearly describe your dispute in the *DESCRIPTION OF DISPUTE* field and outline your *EXPECTED OUTCOME*. Attach any additional information if necessary.
7. Finally, provide your contact details including name, title, phone number, and sign the form before submission.

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