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Provider Disputes Form
Requestor Information
Name
Phone
Street Address
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Provider Information
Provider Name
Provider Network
Provider Network
In Network
Provider Network
Out Of Network
Provider NPI
Provider TIN
Member Information
Member ID
Member First Name
Member Last Name
Claim Information
Claim Number
Service From Date
Service To Date
Billed Amount
Disputed Amount
Dispute Details
Dispute Reason
Dispute Reason Description
Claim underpayment
Allowable Rate dispute
Contractual denials (services not covered)
Missing prior authorization
Medical necessity denials
