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. ·          Provide additional information to support the description of the dispute.  Do not include a copy of a claim that was previously processed. ·          For routine follow-up, please use the Provider Inquiry Request form instead of this form.                 Mail the completed form to the following address:                                                                                 Serra Community Medical Clinic, Inc                                                                                                              9375 San Fernando Rd                                                                                                                                     Sun Valley, CA 91352                                                                                                                                         Attn: Claims Supervisor                                                                                 (818) 768-3000 or visit our website: www.serramedicalclinic.com For provider dispute inquiries or filling information, please contact us at the above listed phone number.

                                                                  

* PROVIDER NAME:	PROVIDER TAX ID #:
PROVIDER ADDRESS:	CONTRACTED: (PLEASE CHECK ONE) _______ Y      _____ N

PROVIDER TYPE            Physician           Mental Health       Hospital        ASC/Outpatient Services       SNF           DME

     

       Rehab             Home Health         Ambulance           Other Professional (please specify type) __________________________

 

 

* CLAIM INFORMATION             Single               Multiple “LIKE” Claims (complete attached spreadsheet) Number of Claims_______

Patient Name:		Date Of Birth:
Social Security Number:	Subscriber Id/CIN Number:	Original Claim Number: (If Multiple Claims, Use Attached Spreadsheet)
Service “From/To” Date:	Original Claim Amount Billed:	Original Claim Amount Paid:

 

Dispute Type:          Claim           Appeal of Medical Necessity/Utilization Management Decision          Contract Dispute

 

       Seeking Resolution of a Billing Determination          Disputing a Request for Reimbursement of Overpayment         Other

 

 

 

 

 

 

 

 

 

 

 

 

 

_______________________________________      _______________________     (______)____________________

CONTACT NAME (please print)                                   TITLE                                          AREA CODE & PHONE NUMBER

 

_______________________________________                      ____________                          (______)____________________

SIGNATURE                                                                 DATE                                         AREA CODE & FAX NUMBER

 

_______________________________________     [   ]  CHECK HERE IF ADDITIONAL INFORMATION IS ATTACHED

E-MAIL ADDRESS                                                            (please do not staple additional information)

 

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