Claims Dispute InquiriesAll fields with an asterisk (*) MUST be completed Contact InformationName* First Last Phone*FaxEmail* Provider InformationTax I.D. Number* Provider Name*As listed in box 31 of the HCFA-1500 / box 1 of the UB-04. Group Name Claim InformationClaim Type Facility Professional Payor Type* Commercial Medicare Advantage Medicaid Payor Aetna US Healthcare Cigna Humana ChoiceCare United Healthcare Other Third Party Administrator (TPA) Payor Humana ChoiceCare WellCare of Kentucky Payor Humana CareSource Passport Health Plan WellCare of Kentucky Member ID* Member Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Employer Group Name (if applicable) Payor Claim Number* Patient Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Type of Bill(i.e. 111, 131, etc.) Codes for ReviewPlease list which codes on the claim you wish to have reviewed. From (MM/DD/YY)To (MM/DD/YY)POSCodeModifierBilled ChargePayor Allowed Codes for ReviewPlease list which codes on the claim you wish to have reviewed. Rev.HCPCSServ. DateUnitsChargePayor Allowed RequestChoose one of the below requests.* Review the denied claim(s) Question allowed amount Reprocess as participating provider Claim upload*Please upload a copy of the claim in question. Drop files here or Select files Max. file size: 50 MB. EOB upload*Please upload a copy of the explanation of benefits associated with the claim. Drop files here or Select files Max. file size: 50 MB. Member ID Card uploadPlease upload a copy of the member's ID card. Drop files here or Select files Max. file size: 50 MB. CommentsPlease list any additional information that might assist us in reviewing your request.EmailThis field is for validation purposes and should be left unchanged.
