October 2019

Medicaid Dispute Request Forms: Which Form to Use and When

If you are a provider who is contracted to provide care and services to our Blue Cross Community Health Plans^SM (BCCHP^SM) and/or Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM members, you are likely familiar with our Provider Claims Inquiry or Dispute Request Form. Please note that this form should only be used for claim-related inquiries. The Provider Claims Inquiry or Dispute Request Form should not be used for service authorization denial disputes.

To help ensure your request is routed appropriately, we have updated the Provider Claims Inquiry or Dispute Request Form on our Provider website. We have also added a new Provider Service Authorization Dispute Resolution Request Form. Both forms are available in the Medicaid section, under the Related Resources.

See below for a quick summary with direct links to each form, an explanation of the purpose of each form, brief definitions and examples, and instructions on where to mail or fax your request. If you have any questions, contact Customer Service at 877-860-2837 for BCCHP, or 877-723-7702 for MMAI.

Provider Service Authorization Dispute Resolution Request Form	Provider Claims Inquiry or Dispute Request Form
Use this form to file a written pre-service authorization dispute resolution request related to an adverse determination.	Use this form to file written requests for claim-related inquiries and disputes.
Examples of adverse determinations include but are not limited to: Authorization denial, or A reduction, suspension, or termination of a previously authorized service.	A claim status inquiry is a request for more information on the resolution of a submitted claim that is not intended to result in a change of the claim payment amount. A claim status inquiry can be made with electronic data interchange (EDI) routing numbers or other applicable information if claim number(s) are not available. A claim dispute is a request for review and reconsideration of a claim nonpayment or payment amount. Claim disputes should be filed with the specific claim numbers that need to be reconsidered for payment with the explanation for payment re-evaluation. Claim disputes are not intended for reconsideration of any pre-service determinations.
Submit your completed Provider Service Authorization Dispute Resolution Request Form, along with the necessary supporting documentation, as follows. Mail Blue Cross Community Health Plans Provider Authorization Disputes P.O. Box 660906 Dallas, TX 75266 Fax 312-653-9443	Submit your completed Provider Claims Inquiry or Dispute Request form by mail or fax, as follows. Mail Blue Cross Community Health Plans c/o Provider Services P.O. Box 4168 Scranton, PA 18505 Fax 855-756-8727 (Claims Inquiry Only) 855-322-0717 (Claims Dispute Only)