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Ir ptcbio static-files 9b67142f-514d-4 2026

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The document outlines the process for submitting a Provider Dispute Resolution Request, including required information such as provider details, claim information, and dispute type. It provides instructions for completing the form, specifies what additional information may be included, and indicates where to send the completed form. The document also includes a tracking form for internal use by the health plan to monitor the status of disputes.

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Click ‘Get Form’ to open it in the editor.
Begin by filling in the required fields marked with an asterisk (*), such as PROVIDER NPI, PROVIDER NAME, and PATIENT NAME. Ensure accuracy as these details are crucial for processing your dispute.
In the CLAIM INFORMATION section, specify whether you are submitting a single or multiple claims. If multiple claims are involved, attach a spreadsheet detailing each claim.
Provide a clear DESCRIPTION OF DISPUTE and EXPECTED OUTCOME. Be specific and include any additional information that supports your case.
Complete the CONTACT NAME, TITLE, PHONE NUMBER, and SIGNATURE sections at the bottom of the form to finalize your submission.
Once all fields are filled out correctly, review your entries for accuracy before submitting via mail or fax as indicated in the instructions.

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