PROVIDER DISPUTE RESOLUTION REQUEST
[Pages:1]PROVIDER DISPUTE RESOLUTION REQUEST
INSTRUCTIONS ? Please complete the below form. Fields with an asterisk ( * ) are required. ? Be specific when completing the DESCRIPTION OF DISPUTE and EXPECTED OUTCOME. ? Provide additional information to support the description of the dispute. Do not include a copy of a claim that
was previously processed. ? For routine follow-up, please use the Claims Follow-Up Form instead of the Provider Dispute Resolution Form. ? Mail the completed form to: Key Medical Group, Inc
3335 S. Fairway Visalia, CA 93277 ? Or by fax: (559) 734-6203
*PROVIDER NPI: *PROVIDER NAME:
PROVIDER ADDRESS:
PROVIDER TAX ID:
PROVIDER TYPE
SNF
DME
* Patient Name:
MD
Mental Health Professional
Mental Health Institutional
Hospital
ASC
Rehab
Home Health
Ambulance Other ____________________________
(please specify type of "other")
Date of Birth:
* Health Plan ID Number:
Patient Account Number:
Original Claim ID Number:
Service "From/To" Date: ( * Required for Claim, Billing, and
Reimbursement Of Overpayment Disputes)
Original Claim Amount Billed: Original Claim Amount Paid:
DISPUTE TYPE Claim
Appeal of Medical Necessity / Utilization Management Decision
Disputing Request For Reimbursement Of Overpayment
Seeking Resolution Of A Billing Determination Contract Dispute Other:
* DESCRIPTION OF DISPUTE:
EXPECTED OUTCOME:
Contact Name (please print)
Signature
[ ] CHECK HERE IF ADDITIONAL INFORMATION IS ATTACHED (Please do not staple)
ICE Approved 10/5/07, effective 1/1/08
Title Date
Phone Number
(
)
Fax Number
For Health Plan/RBO Use Only TRACKING NUMBER ________________________ PROV ID# __________
CONTRACTED _____ NON-CONTRACTED _____
................
................
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