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P.O. Box 3050 Farmington, MO 63640-3821 ATC-06102020-P-3 : Title: Provider Dispute Form Author: Centene Subject: Medicaid-Provider-DisputeForm-2020-508R Keywords: PO Box 5010 Farmington, MO 63640-5010 . Claim Disputes: (Form located on website) Ambetter from Superior HealthPlan PO Box 5000 Farmington, MO 63640-5000 . Corrected Claims, Requests for Reconsideration or Claim Disputes: 120 days from the date of explanation of payment or denial is issued . Timely Filing DeadlineMail completed form(s) and attachments to the appropriate address: Ambetter from Home State Health Plan Attn: Level I – Request for Reconsideration PO Box 5010 …State Managed Care Phone Claims Address AK Alaska Medicaid 907-644-6800 AK 800-783-9207 AK 800-884-3223 AL Alabama Medicaid 800-688-7989 AL BCBS AR AR 501-374-6608 AR Ambetter AR 855-429-1028 PO BOX 211446 Eagan MN 55121 AZ Arizona Medicaid 602-417-7670 AHCCCS, PO Box 1700 Phoenix, AZ 85002 AZ 602-417-7670 …9.2.2018 ... P.O. Box 5000 – Farmington, MO 63640-5000. Page 33. Claim Submission. Member in Suspended Status: • A provision of the ACA allows members who ...Ambetter from Home State Health Plan Attn: Level II - Claim Dispute PO Box 5000 Farmington, MO 63640-5000 Ambetter.HomeStateHealth.com ©2018 Home State Health Plan. All rights reserved. Ambetter Provider Services: 1-855-650-3789 AMB18-MO-H-002P.O. Box 5080 Farmington, MO 63640-5080 Claims sent to any other address will be returnedafter COB Submission When MPC is secondary, provider has 12 months from the date of service COB claims are accepted up to 6 months a Remittance Advice date up to 18 months from the date of service Original Claim PO Box 5000 Farmington, MO 63640-5000 Corrected Claims, Requests for Reconsideration or Claim Disputes: 180 days from the date of explanation of payment or denial is issued EFT/ERA - PaySpan Health To register call: 1 …PO Box 5000 Farmington, MO 63640-5000. Complaint/Grievance. A Complaint/Grievance is a verbal or written expression by a provider which indicates dissatisfaction or dispute with Ambetter’s policies, procedure, or any aspect of Ambetter’s functions. Ambetter logs and tracks all complaints/grievances whether received verbally or in writing.P.O. Box 3003 Farmington, MO 63640-3803. Ambetter from Superior HealthPlan Attn: Claims P.O. Box 5010 Farmington, MO 63640-5010. PaySpan - EFT/ERAPO Box 5000 Farmington, MO 63640-5000. Complaint/Grievance. A Complaint/Grievance is a verbal or written expression by a provider which indicates dissatisfaction or dispute with Ambetter’s policies, procedure, or any aspect of Ambetter’s functions. Ambetter logs and tracks all complaints/grievances whether received verbally or in writing.PO Box 5000 Farmington, MO 63640-5000. Complaint/Grievance. A Complaint/Grievance is a verbal or written expression by a provider which indicates dissatisfaction or dispute with Ambetter’s policies, procedure, or any aspect of Ambetter’s functions. Ambetter logs and tracks all complaints/grievances whether received verbally or in writing.Wellcare By Allwell Medicare (MAPD, D-SNP & PPO) Appeal : An Appeal is the mechanism which allows Providers the right to appeal actions of Wellcare By Allwell such as a pre-service prior authorization denial. If authorization was denied pre-service or during concurrent review, follow appeal instructions on the notification letter.PO Box 5000 Farmington, MO 63640-5000 Disputes of Denials for Lack of Medical Necessity: Disputes must include an explanation outlining why the original decision is incorrect. Simply sending in records will not result in further review. Disputes of Denials for Failure to Pre-Authorize: Disputes must include documentation X Important Information about COVID-19. Because of the current health crisis, it is possible that our call centers, including the nurse advice line, may experience high call volume.PO BOX 5000 • Farmington, MO 63640- 5000 : Corrected Claim, Reconsideration, Claim Disputes 12/15/2014 : Claim Submission : Member in Suspended Status: Following ... PO Box 44287 : Detroit, MI 48244 . Fax Number: 833-383-1503 . Goes quite far back and has lots of PO Bo PO Box 5010 Farmington, MO 63640 -5010 . Ambetter from Sunshine Health ... Farmington, MO 63640 -5000. Title: Florida - Provider Request for Reconsideration and Claim ... 1-800-929-9955. Website: www.healthnet.com. Send All Claims • Claim Reconsiderations may be mailed to PO Box 5010 –Farmington, MO 63640-5010 Claim Disputes • Must be submitted within 90 days of the Explanation of Payment • A Claim Dispute form can be found on our website at Ambetter.mhsindiana.com • The completed Claim Dispute form may be mailed to PO Box 5000 –Farmington, MO 63640-5000Claim Disputes: (Form located on website) Ambetter from Superior HealthPlan PO Box 5000 Farmington, MO 63640-5000. Corrected Claims, Requests for Reconsideration or … 8325 Lenexa Drive, Suite 410 Lenexa KS 66214 Provider claim d

PO Box 5010 . Farmington, MO 63640-5010 *All submissions sent through the portal allow for real-time tracking of Reconsideration Status. Claim Appeal . 1. Mail completed form(s) …PO Box 9040 Farmington, MO 63640-9040 Commercial Provider Services Center 1-800-641-7761 Health Net Medi-Cal Provider Appeals Unit PO Box 989881 West Sacramento, CA 95798-9881 Medi-Cal Provider Services Center 1-800-675-6110 *Provider name: *Provider tax ID #: Contracted? Yes No P.O. Box 3070 Farmington, MO 63640-3823 Attn: Claims Department. Sunshine Health Plan ... P.O. Box 459089 Fort Lauderdale, FL 33345-9089 Phone: 1-866-796-0530P.O. Box 8001 Farmington, MO 63640-3001. If you prefer to refund the overpayment by check (on your check stock), include a copy of the EOP and send to: Delaware First Health P.O. Box 8001 Farmington, MO 63640-3001. For Behavioral Health Claims, send to: Delaware First Health ATTN: Behavioral Health Claims P.O. Box 8001 Farmington, MO 63640-3001

PO Box 5000 Farmington, MO 63640-5000. Complaint/Grievance. A Complaint/Grievance is a verbal or written expression by a provider which indicates dissatisfaction or dispute with Ambetter’s policies, procedure, or any aspect of Ambetter’s functions. Ambetter logs and tracks all complaints/grievances whether received verbally or in writing.X Important Information about COVID-19. Because of the current health crisis, it is possible that our call centers, including the nurse advice line, may experience high call volume.…

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