Fillable PROVIDER DISPUTE RESOLUTION REQUEST (CalOptima)

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PROVIDER DISPUTE RESOLUTION REQUEST (CalOptima)

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The PROVIDER DISPUTE RESOLUTION REQUEST (CalOptima) form is 2 pages long and contains:

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  • 26 check-boxes
  • 180 other fields

Country of origin: US
File type: PDF

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PROVIDER DISPUTE RESOLUTION REQUEST
INSTRUCTIONS
x Please complete this form. Fields with an asterisk ( * ) are required.
x Be specific when completing the DESCRIPTION OF DISPUTE and EXPECTED OUTCOME.
x Provide additional information to support the description of the dispute.
x For routine follow-up regarding claims status, please contact the CalOptima Claims Provider Line: 714-246-8885
x Mail the completed form to: CalOptima Claims Provider Dispute
P.O. Box 57015
Irvine, CA 92619
PRODUCT TYPE:
MEDI-CAL MEDICARE COMMERCIAL
* PROVIDER NPI:
* PROVIDER TAX ID # / Medicare ID #:
* PROVIDER NAME:
CONTRACTED: YES
NO
PROVIDER ADDRESS:
PROVIDER TYPE MD Mental Health Professional Mental Health Institutional Hospital ASC
SNF DME Rehab Home Health Ambulance Other
(please specify type of “other”)
CLAIM INFORMATION Single Multiple “LIKE” Claims (complete attached spreadsheet) Number of claims:
* Patient Name:
Date of Birth:
* Health Plan ID Number:
Patient Account Number:
Original Claim ID Number: (If multiple
claims, use
attached spreadsheet)
Service “From/To” Date: ( * Required for Claim,
Billing, and
Reimbursement of Overpayment Disputes)
Original Claim Amount
Billed:
Original Claim Amount
Paid:
DISPUTE TYPE
Claim Seeking Resolution of a Billing Determination
Appeal of Medical Necessity / Utilization Management Decision Contract Dispute
Disputing Request for Reimbursement of Overpayment Other:
* DESCRIPTION OF DISPUTE:
EXPECTED OUTCOME:
Contact Name (please print) Title
Signature Date
( )
Phone Number
( )
Fax Number
CHECK HERE IF ADDITIONAL
INFORMATION IS ATTACHED
For Health Plan Use Only
(Please do not staple.)
TRACKING # PROV ID#
CONTRACTED NON-CONTRACTED
click to sign
signature
click to edit
PROVIDER DISPUTE RESOLUTION REQUEST
Tracking Form
(For Optional Use by Health Plan/Delegated Provider)
Number
* Patient Name
Date of
Birth
* Health Plan ID
Number
Original Claim ID
Number
* Service
From/To
Date
Original
Claim
Amount
Billed
Original
Claim
Amount Paid
Expected Outcome
Last
First
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CHECK HERE IF ADDITIONAL
INFORMATION IS ATTACHED
(Please do not staple)
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PROVIDER DISPUTE RESOLUTION REQUEST (CalOptima)

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Completed 11 March 2021

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