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Performant discussion period request form 2026

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The document is a Discussion Period Request Form from Performant Recovery, Inc. for providers or suppliers to contest decisions made during Recovery Audits (RA). It includes sections for provider information, claim details, reasons for disagreement, and instructions for submission via mail or fax. The form aims to facilitate communication regarding audit results and allows for the attachment of additional documentation.

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Click ‘Get Form’ to open the performant discussion period request form in the editor.
Begin by entering your Provider/Supplier Name, NPI, and TAX-ID in the designated fields. This information is crucial for identifying your account.
Fill in the CLAIM# and select the Type of Audit from the options provided: Automated, Complex, or Semi-Automated. For automated audits, include the date of the MAC Demand Letter.
Indicate whether you have additional documentation attached by selecting 'Yes' or 'No'. If you disagree with the RA’s decision, provide detailed reasons in the space provided.
Sign and date the form at the bottom. Ensure that your printed name and phone number are clearly stated along with your email address for any follow-up communication.

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Versions	Form popularity	Fillable & printable
2020	4.7 Satisfied (55 Votes)
2013	4.6 Satisfied (42 Votes)
2013	4 Satisfied (40 Votes)

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