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Member Handbook (EOC)

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Medicare and Medi-Cal benefits

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Community y Más

Medicare plan for chronic care needs

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Provider Dispute Resolution (PDR) Request

Resources for Providers

Community Health Group

PROVIDER DISPUTE RESOLUTION (PDR) REQUEST

NOTE: SUBMISSION OF THIS FORM CONSTITUTES AGREEMENT NOT TO BILL THE PATIENT
*Provider TIN
Provider Name
Provider Address
*Email Address
Fax
Provider Type
Patient Last Name
Patient First Name
*Date of Birth
CHG ID
Patient Account Number
*Original Claim ID Number
*Service Date
Original Claim Amount Billed
Original Claim Amount Paid
*Dispute Type

Please check this box if you received a Notice of Action denial letter from Utilization Management and would like to appeal the denial for medical necessity.

FILL OUT THIS SECTION TO REQUEST A PDR FOR MEDICAL NECESSITY REVIEW:
Please check one:
*Authorization reference number:
*Requested Service:
*Have these services been rendered?
*Expected Outcome:
*Description of Dispute/Explanation:
Contact Name
Phone Number

Provider Information

Please check this option if you received a Notice of Action denial letter from the Utilization Management (UM) Department and would like to appeal the denial based on medical necessity. Complete the next section.
Complete this section only when PDR Appeal for Medical Necessity is selected.
Please select one
Have these services been rendered?

Make sure to:

  • Attach a copy of the NOA Denial Letter
  • Attach any supporting clinical documentation; NOTE: Please only send clinical records that are pertinent for the DOS you are contesting.
  • Provide a clear explanation as to why the denial decision should be overturned in the space provided below.
Add another

Dispute Type or Medical Necessity is required.

Please make sure all fields from Medical Necessity section have a value.