Get the free NON PARTICIPATING PROVIDER DISPUTE RESOLUTION

Basinger Health Plan PO Box 853910 Richardson, TX 750853910 Fax number 5702149366NON PARTICIPATING PROVIDER DISPUTE RESOLUTION REQUEST NOTE: SUBMISSION OF THIS FORM CONSTITUTES AGREEMENT NOT TO BILL

How to fill out non participating provider dispute

How to fill out non participating provider dispute

1. Step 1: Gather all relevant documentation such as the Explanation of Benefits (EOB) statement, any correspondence from the insurance company, and any other supporting documents.
2. Step 2: Review the EOB statement and any other relevant documents to understand the reason for the dispute and the amount in question.
3. Step 3: Contact the insurance company's customer service department and inform them of your intention to file a non-participating provider dispute. Obtain any necessary forms or instructions for filing the dispute.
4. Step 4: Fill out the non-participating provider dispute form accurately and completely, including all required information such as your contact details, the name of the provider, the disputed charges, and the reason for the dispute.
5. Step 5: Attach any supporting documentation to the dispute form, such as copies of the EOB statement or any correspondence that highlights the discrepancies or errors.
6. Step 6: Make a copy of the completed dispute form and all supporting documents for your records.
7. Step 7: Submit the dispute form and supporting documents to the designated address provided by the insurance company. Consider sending the documents via certified mail or with delivery confirmation to ensure they are received.
8. Step 8: Keep a record of the date and time when the dispute documents were sent, as well as any tracking numbers or other relevant information.
9. Step 9: Follow up with the insurance company after a reasonable amount of time has passed to ensure that the dispute is being processed and to inquire about any additional steps or information that may be required.
10. Step 10: Continue to communicate with the insurance company until a resolution is reached. Be proactive in providing any requested information or additional documentation to support your claim.
11. Step 11: Keep records of all correspondence, including names and contact information of insurance company representatives, for future reference.
12. Step 12: If a satisfactory resolution is not achieved through the non-participating provider dispute process, consider seeking legal advice or contacting a consumer advocacy organization for further assistance.

Who needs non participating provider dispute?

1. Anyone who has received medical services from a non-participating provider and believes they have been billed incorrectly or unfairly may need to file a non-participating provider dispute.
2. This could include individuals with private health insurance plans, Medicare beneficiaries, or individuals participating in other government-sponsored healthcare programs.

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What is non participating provider dispute?

Non participating provider dispute is a process where a healthcare provider challenges the payment or denial of a claim by an insurance company that they do not have a contract with.

Who is required to file non participating provider dispute?

The healthcare provider who did not have a contract with the insurance company and is disputing the payment or denial of a claim is required to file a non participating provider dispute.

How to fill out non participating provider dispute?

The non participating provider dispute can be filled out by providing detailed information about the claim, the services provided, and reasons for disputing the payment or denial.

What is the purpose of non participating provider dispute?

The purpose of non participating provider dispute is to resolve payment or denial issues between healthcare providers and insurance companies where there is no contract in place.

What information must be reported on non participating provider dispute?

The information that must be reported on non participating provider dispute includes details of the claim, services provided, reasons for disputing, and any supporting documentation.