Claims Dispute Inquiries All 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 NameClaim InformationClaim TypeFacilityProfessionalPayor 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 amountReprocess as participating providerClaim upload*Please upload a copy of the claim in question. Drop files here or EOB upload*Please upload a copy of the explanation of benefits associated with the claim. Drop files here or Member ID Card uploadPlease upload a copy of the member's ID card. Drop files here or CommentsPlease list any additional information that might assist us in reviewing your request.PhoneThis field is for validation purposes and should be left unchanged.