Transcription of PROVIDER DISPUTE RESOLUTION REQUEST
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PROVIDER DISPUTE RESOLUTION REQUEST
PROVIDER DISPUTE RESOLUTION REQUEST [ ] C HEC K HERE IF A DDITIONAL INFORMATION IS ATTAC HED (Please do not staple) IC E Approve d 10/5/07, e ffe ctive 1/1/08 * PROVIDER NPI: PROVIDER TAX ID: * PROVIDER NAME: PROVIDER ADDRESS: PROVIDER TYPE MD Mental Health Professional Mental Health Institutional Hospital ASC SNF DME Rehab Home Health Ambulance Other _____ (please specif y type of other ) CLAIM INFORMATION Single Multiple LIKE Claims (complete attached spreadsheet) Number of claims:___ *Patie nt Nam e : Date of Birth: *Health Plan ID Num ber: Patient Account Num ber: Original Claim ID Num be r: (If multiple claims, use attached spreadsheet) Se rvice From /To Date : ( * Required f or Claim, Billing, andReimbursement Of Overpayment disputes ) Original Claim Am ount Bille d: Original Claim Am ount Paid: Contact Name (please print) Title Phone Number ( ) Signature Da te Fax Number *DESC
The entity processing the Provider Dispute Resolution should track the following information internally for s and for later reporting to the appropriate entity. COMPLETE DESCRIPTION OF DETERMINATION RATIONALE: Title: DRAFT Provider Dispute Resolution 2005 …
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