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Get And Sign Provider Claim Dispute Form

Patient Name Member Name Member RID Number Reason for Dispute please check Claim was denied for no authorization but authorization was obtained. Claim was paid to wrong provider Other please explain below Date of Request Requestor Name Requestor Phone Number ATTACH A Copy of the EOP s with Claim s to be adjusted clearly circled along with the response to your original request for reconsideration. NOTE If original claim submitted requires correction such as a valid procedure code location...

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