
Provider Dispute Claim Reconsideration Request Form CCAI


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People also ask
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How do I appeal a coordinated care of Washington provider?
If you wish to file an appeal in writing, you may use this Appeal Request form (PDF). You can also write a letter that includes the information requested in the form, or you may file an appeal by phone, fax, or in person. If you wish to file an appeal by phone, call us at 1-877-644-4613 or TTY 711.
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What is provider dispute resolution?
A provider dispute is a written notice from the non-participating provider to Health Net that: Challenges, appeals or requests reconsideration of a claim (including a bundled group of similar claims) that has been denied, adjusted or contested. Challenges a request for reimbursement for an overpayment of a claim.
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How do I appeal a Commonwealth Care Alliance provider?
Call: 1-866-333-3530 Calls to this number are free.
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