Provider Dispute Resolution Request
Provider Dispute Resolution Request
Commercial and Medi-Cal
INSTRUCTIONS
? Please complete the form fields below. Fields with an asterisk (*) are required. Forms with incomplete fields may be returned and
delay processing.
? 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 status, please call the appropriate telephone number below.
? Mail the completed form to the following address. Please note the specific address for all Medi-Cal appeals.
Health Net Commercial Provider Appeals Unit PO Box 9040 Farmington, MO 63640-9040 Commercial Provider Services Center 1-800-641-7761
Health Net Medi-Cal Provider Appeals Unit PO Box 989881 West Sacramento, CA 95798-9881 Medi-Cal Provider Services Center 1-800-675-6110
*Provider name:
*Provider tax ID #:
*Provider address
Contracted? Yes No
Provider type: Physician Mental health Hospital ASC/outpatient services SNF DME Rehab Home health Ambulance Other professional (please specify type of other) ______________________________________________
*Claim information: Single Multiple "LIKE" claims (complete attached spreadsheet) Number of claims __________________
*Patient name:
Date of birth:
*Health Plan ID number:
*Subscriber ID/CIN number:
*Original claim ID/Submission ID number: (If multiple claims, use attached spreadsheet)
*Service from/to date:
Original claim amount billed:
Original claim amount paid:
Dispute type: Claim Appeal of medical necessity/utilization management decision Contract dispute Seeking resolution of a billing determination Disputing a request for reimbursement of overpayment Other *Description of dispute: Indicate reason for dispute, provider's position and reasoning: (Additional paper can be attached if necessary)
*Expected outcome: (Please provide by claim if multiple.)
______________________________________________ ___________________________________________ _(_______)__________________________________
Contact name (please print)
Title
Area code and phone number
______________________________________________ ___________________________________________ _(_______)__________________________________
Signature and date
Email address
Area code and fax number
Check here if additional information is attached: (Please do not staple information.)
Page ____ of ____
For Health Plan Use Only
Case# Provider#
Health
Net
of
California,
Inc.,
Health
Net
Community
Solutions,
Inc.
and
Health
Net
Life
Insurance
Company
are
subsidiaries
of
Health
Net,
Inc.
and
Centene
Corporation.
Health
Net
is
a
registered
service
mark
of
Health
Net,
Inc.
All
rights
reserved.
21-225a/FRM047551EC00 (3/21)
Commercial and Medi-Cal Provider Dispute Resolution Request, continued
INSTRUCTIONS (for use with multiple like claims only)
? Please complete the form fields below. Fields with an asterisk (*) are required. Forms with incomplete fields may be returned and delay processing.
? 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 status, please call the appropriate telephone number below.
? Mail the completed form to the following address. Please note the specific address for all Medi-Cal appeals.
Health Net Commercial Provider Appeals Unit
Health Net Medi-Cal Provider Appeals Unit
PO Box 9040 Farmington, MO 63640-9040
PO Box 989881 West Sacramento, CA 95798-9881
Commercial Provider Services Center 1-800-641-7761
Medi-Cal Provider Services Center 1-800-675-6110
Number Last
*Patient name First
Date of birth
*Subscriber ID/CIN number
*Original claim ID/Submission ID number
*Service from/to date
Original
Original
claim amount claim amount *Expected outcome
billed
paid
1
2
3
4
5
6
7
8
9
10
11
12
Check here if additional information is attached: (Please do not staple information.)
21-225a/FRM047551EC00 (3/21)
Page ____ of ____
For Health Plan Use Only
Case#
Provider#
................
................
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