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PROVIDER DISPUTE RESOLUTION REQUEST INSTRUCTIONS Please complete the below form. Fields with an asterisk (*) are required. Be specific when completing the DESCRIPTION OF DISPUTE and EXPECTED OUTCOME.
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Provide additional information to is a form or document where additional details or explanations are given.
Any individual or entity who is requested to provide additional information by a governing body or organization.
To fill out provide additional information to, one must carefully read the instructions provided and complete all required fields accurately.
The purpose of provide additional information to is to ensure that all relevant details and explanations are provided to support a particular claim or request.
The specific information that must be reported on provide additional information to will depend on the nature of the request or claim being made.
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California Torrance NPI DME ASC RBO TIMEFRAME SNF Crenshaw IPA orDETERMINATION Overpayment PROV Reimbursement Utilization Delegated disputed Disputing spreadsheet applicable Institutional UPHELD RATIONALE asterisk ensuring TURNAROUND Disputes Blvd Billed

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