Medicaid Expansion Provider Dispute Form

This form is to be used to submit a Provider Dispute. The Provider Complaint system permits the submission of a dispute on BCBSND’s policies, procedures, or any aspect of BCBSND’s administrative functions, including proposed actions, claims/billing disputes, and service authorizations.

* Required fields

Is this dispute claim related? Yes

Has an appeal been submitted for this dispute? Yes

Member Information

Member First Name

Member Last Name

Member Date of Birth

Please enter a valid Date.

Member ID Number

Member Phone Number

Provider Information

Provider First Name

Provider Last Name

Facility Name

Provider NPI

Provider Phone Number

Provider Fax Number

Address

Address Line 2

City

ZIP Code

Submitter Information

*Required Fields

Submitter First Name

Submitter Last Name

Address Line 1

Address Line 2

City

ZIP Code

Phone Number

Fax Number

Claims Information

Reference Information

Review

Member Information

Member First Name : Edit

Member Last Name : Edit

Member Date of Birth : Edit

Member ID Number : Edit

Member Phone Number : Edit

Provider Information

Provider First Name : Edit

Provider Last Name : Edit

Facility Name : Edit

Provider NPI : Edit

Provider Phone Number : Edit

Provider Fax Number : Edit

Address : Edit

Address Line 2 : Edit

City : Edit

State : Edit

ZIP Code : Edit

Submitter Information

Submitter First Name : Edit

Submitter Last Name : Edit

Address Line 1 : Edit

Address Line 2 : Edit

City : Edit

State : Edit

ZIP Code : Edit

Phone Number : Edit

Fax Number : Edit

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Print this page for your records before submitting the application.

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Medicaid Expansion Provider Dispute Form

Member Information

Provider Information

Submitter Information

Claims Information

Reference Information

Review