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How do I fill this out?
To fill out the form, start by providing all required information accurately. Ensure that you check the appropriate level of dispute. Finally, attach any supporting documents as outlined.
How to fill out the Provider Request for Reconsideration and Claim Dispute?
1
Gather all necessary information including provider details.
2
Select the dispute level - Level I or Level II.
3
Clearly state the reason for the dispute.
4
Attach supporting documents if applicable.
5
Submit the form to the designated address based on the dispute level.
Who needs the Provider Request for Reconsideration and Claim Dispute?
1
Providers seeking to appeal a denied claim.
2
Healthcare professionals disputing payment amounts.
3
Billing departments requiring clarification on claims.
4
Medical practices correcting claim submission errors.
5
Insurance representatives assessing reconsideration requests.
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1
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What are the instructions for submitting this form?
To submit the completed form, send it via the mail to Ambetter of North Carolina Inc., Attn: Level I or II depending on your dispute type. The mailing address is PO Box 5010 or PO Box 5000, Farmington, MO 63640-5010. Ensure that all required documents are included with your submission for effective processing.
What are the important dates for this form in 2024 and 2025?
For 2024, please note that submission deadlines will remain the same as previous years. It's crucial to file your requests within the specified time frames. Key dates will be reviewed annually.
What is the purpose of this form?
The purpose of this form is to allow healthcare providers to formally request reconsideration of claim decisions. It serves as a structured method for disputing claims that have been denied or underpaid. By using this form, providers can ensure that their claims are reviewed and adjudicated fairly.
Tell me about this form and its components and fields line-by-line.
- 1. Provider Name: The name of the healthcare provider submitting the request.
- 2. Provider Tax ID #: The unique tax identification number associated with the provider.
- 3. Control/Claim Number: The reference number for the claim being disputed.
- 4. Date(s) of Service: The date(s) on which the services were provided to the member.
- 5. Member Name: The name of the patient/member whose claim is being disputed.
- 6. Member (RID) Number: The unique identification number for the member.
What happens if I fail to submit this form?
Failing to submit this form can result in delayed resolution of your claim disputes. Claims may remain unpaid or unresolved, leading to financial discrepancies. Timely submission is critical for effective claim management.
- Delay in Claim Resolution: Without submission, claim disputes may not be addressed, resulting in payment issues.
- Financial Burden: Providers may face unanticipated financial strain without resolved claims.
- Lack of Proper Documentation: Failure to submit may result in incomplete records for future reference.
How do I know when to use this form?
- 1. Claim Denial Appeals: Use this form when appealing a claim that has been denied.
- 2. Payment Amount Disputes: If you believe the payment amount is incorrect, submit this form.
- 3. Authorization Issues: Applicable if your claim was denied for authorization but you have proof.
Frequently Asked Question
How do I submit the completed PDF?
You can submit it via mail or fax to the designated addresses provided in the guidelines.
What information is needed to fill out the form?
You will need provider details, claim numbers, and reasons for the dispute.
Can I edit the PDF before submitting it?
Yes, use the PrintFriendly editor to make necessary changes easily.
Is there a time limit for submission?
Yes, the form must be submitted within 180 days for participating providers.
What should I do if my claim was denied?
Complete the form and clearly state the reason for the dispute related to your claim.
Can I attach supporting documents?
Yes, ensure you include any relevant documents that support your dispute.
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What if I need help while filling out the form?
Refer to the instructions provided or contact support for assistance.
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Absolutely, you can easily share the edited PDF via email or link.
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