Definition of Contracted Provider Dispute
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A contracted provider dispute is a provider's written notice to Health Net challenging, appealing, or requesting reconsideration of a claim (or a bundled group of substantially similar claims that are individually numbered) that has been denied, adjusted, or contested, or seeking resolution of a billing determination or other contract dispute (or bundled group of substantially similar multiple billing or other contractual disputes that are individually numbered), or disputing a request for reimbursement of an overpayment of a claim.
Each contracted provider dispute must contain, at a minimum, the following information: provider's name, billing provider's Tax ID number or Health Net’s provider ID number, provider's contact information, and:
If the contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from Health Net to a contracted provider, the following must be provided:
- Original claim form number (located on the RA).
- A clear identification of the disputed item.
- The date of service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment, or other action is incorrect.
If the contracted provider dispute is not about a claim:
- A clear explanation of the issue and the provider's position on such issue.
If the contracted provider dispute involves an enrollee or group of enrollees:
- The name and identification number(s) of the enrollee or enrollees.
- A clear explanation of the disputed item, including the date of service.
- Provider's position on the disputeAn enrollee's written authorization for the provider to represent said enrollees.