Ambetter Provider Reconsideration and Claim Dispute Form
This document is essential for providers looking to request a reconsideration or dispute a claim with Ambetter from Coordinated Care. It outlines the process, required information, and submission guidelines. Ensure to follow the instructions for a smooth submission and resolution.
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How do I fill this out?
To fill out this form, start by gathering all necessary information such as your provider name, tax ID, and claim details. Ensure that you provide accurate information in each required field to avoid delays. After completing the form, submit it according to the provided instructions.
How to fill out the Ambetter Provider Reconsideration and Claim Dispute Form?
1
Gather all required information including provider details.
2
Select the level of dispute and reason for dispute.
3
Complete the requestor information section.
4
Attach any necessary supporting documents.
5
Submit the completed form to the appropriate address.
Who needs the Ambetter Provider Reconsideration and Claim Dispute Form?
1
Healthcare providers who have disputes with claims processing.
2
Billing departments seeking to rectify denied claims.
3
Medical offices needing clarification on claim payments.
4
Providers looking to appeal for reconsideration after claim denials.
5
Providers who need to address payment discrepancies.
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What are the instructions for submitting this form?
To submit this form, mail the completed document along with any supporting documents to the designated address for Level I or Level II disputes. For Level I, send to: Ambetter from Coordinated Care, Attn: Level I - Request for Reconsideration, PO Box 5010, Farmington, MO 63640-5010. For Level II, send to: Ambetter from Coordinated Care, Attn: Level II - Claim Dispute, PO Box 5000, Farmington, MO 63640. Consider sending via trackable mail for confirmation of receipt.
What are the important dates for this form in 2024 and 2025?
Ensure submissions for reconsideration or disputes are made within 24 months from the original EOP or denial date. Important dates for 2024 and 2025 will be relevant when planning claim disputes. Check for any updates on policy changes that might affect these timelines.
What is the purpose of this form?
The purpose of this form is to allow healthcare providers to formally request a reconsideration of denied claims or to dispute claims that have not been processed correctly. By providing a clear and structured means to communicate with Ambetter from Coordinated Care, providers can address issues that impact their practice and revenue cycle. This form is crucial for maintaining effective communication between providers and the insurance company.
Tell me about this form and its components and fields line-by-line.
- 1. Provider Name: Enter the full name of the healthcare provider.
- 2. Provider Tax ID #: Include the tax identification number associated with the provider.
- 3. Control/Claim Number: Provide the control or claim number related to the dispute.
- 4. Date(s) of Service: Specify the date(s) when the service was rendered.
- 5. Member Name: Enter the name of the member associated with the claim.
- 6. Member (RID) Number: Include the member's RID number provided by the insurance.
- 7. Level of dispute: Select whether this is a Level I Request for Reconsideration or Level II Claim Dispute.
- 8. Reason for Dispute: Indicate the reason for the claim dispute by checking the appropriate box.
- 9. Requestor Name: Provide the name of the individual submitting this request.
- 10. Requestor Phone Number: Enter a phone number where the requestor can be reached.
- 11. Date of Request: Date on which the request is being submitted.
What happens if I fail to submit this form?
Failure to submit this form can result in unresolved claim discrepancies, forcing you to bear financial losses. Claims may remain denied without an official request for reconsideration or dispute. It's crucial to adhere to submission deadlines to ensure your issues are addressed properly.
- Delayed Payments: Without submission, claims will not get resolved, causing payment delays.
- Unresolved Disputes: Filing is essential for formally addressing issues; otherwise, they may linger.
- Loss of Revenue: Denial of claims can lead to significant income losses for providers.
How do I know when to use this form?
- 1. Dispute Denied Claims: Use this form to challenge decisions on claims that have been denied.
- 2. Request Reconsideration: Formalize a request for revising the outcomes related to claim processing.
- 3. Correct Payment Issues: Address any discrepancies regarding payment amounts or incorrect provider payments.
Frequently Asked Questions
How do I submit the Claim Dispute form?
Submit the completed form by mail or fax to the addresses provided. Ensure all required fields are filled out completely.
What information is necessary to fill out the form?
You will need your provider name, tax ID, member details, and reason for the dispute.
Can I edit the PDF form before submitting?
Yes, you can use PrintFriendly to edit the PDF directly.
What happens if I miss the deadline for submission?
Timely submission is essential. Late submissions may be rejected based on the claims processing rules.
Is there a limit to how many disputes I can file?
There is no limit, but each claim must be eligible for reconsideration or dispute.
Can I attach supporting documents?
Yes, always include relevant documentation to support your claims.
Where can I find the mailing address?
The mailing address is included in the form instructions at the bottom.
What if my claim is still denied after reconsideration?
You may proceed to submit an appeal with additional documentation.
How can I check the status of my dispute?
You can check your claim status by contacting Ambetter customer service after submission.
What if I need assistance filling out the form?
Customer support is available to provide guidance on completing the form.
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