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Provider Request for Reconsideration and Claim Dispute Form

_____ _____ Provider Request FOR Reconsideration AND Claim Dispute form Use this form as part of the Ambetter from Coordinated Care Request for Reconsideration and Claim Dispute process. All fields are required information Provider Name Provider Tax ID # Control/ Claim Number Date(s) of Service Member Name Member (RID) Number A Request for Reconsideration (Level I) is a communication from the Provider about a disagreement with themanner in which a Claim was processed. A Claim Dispute (Level II) should be used only when a Provider has received an unsatisfactory response to aRequest for Reconsideration .

claim, Request for Reconsideration, or Claim Dispute) will cause an upfront rejec tion. • If the original claim submitted requires a correction, please submit the corrected claim following the “Corrected Claim” process in the Provider Manual. Please do not include this form with a corrected claim. Level of dispute (please check):

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