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Provider Disputes Form
Step
1
of
2
Note: This is a two-step process requiring at least one document to be uploaded in step 2.
Requestor Information
First Name
*
*
Last Name
*
*
Phone
*
*
Email Address
*
*
Requestor Mailing 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 First Name
*
*
Provider Last 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
