Provider dispute resolution request instructions - Brand New Day 2026

1. Click ‘Get Form’ to open the Provider dispute resolution request in the editor.
2. Begin by filling in your details in the PROVIDER NAME and PROVIDER TAX ID # / MEDICARE ID # fields, ensuring all required fields marked with an asterisk (*) are completed.
3. Provide your PROVIDER ADDRESS and select your PROVIDER TYPE from the options available, including MD, MENTAL HEALTH, HOSPITAL, etc. If you choose 'OTHER', please specify the type.
4. In the CLAIM INFORMATION section, indicate whether it is a Single or Multiple claim. For multiple claims, complete the attached spreadsheet as instructed.
5. Fill out patient details such as Patient Name, Health Plan ID Number, Date of Birth, and Patient Account Number. Ensure you include the Original Claim ID Number if applicable.
6. Select the DISPUTE TYPE that best describes your situation and provide a detailed DESCRIPTION OF DISPUTE along with your EXPECTED OUTCOME.
7. Complete the contact information section by providing your Contact Name, Title, Phone Number, and ensure to sign and date the form before submission.

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