[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-284744-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-284744-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","ppi-medical-record-review-dispute-request-form","PPI Medical Record Review Dispute Request Form","","This document provides the Provider Payment Integrity (PPI) Medical Record Review Dispute Request Form for healthcare professionals to formally contest findings or claim payments associated with Humana services. It requires comprehensive provider information, including name, address, and state of practice, alongside specific claim details like the Humana claim number, dispute type, policy category, and patient identifiers such as name, account number, and Medicaid ID. The form is designed to facilitate accurate documentation routing, ensuring that all necessary supporting materials—including the initial findings letter—are attached for efficient resolution. It assists in delineating between Medicaid, Medicare, and commercial insurance disputes, while identifying the participant status of the provider and the nature of the submitted claim, thereby streamlining administrative workflows and enhancing the clarity of the reconciliation process between the insurer and the healthcare provider.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/ppi-medical-record-review-dispute-request-form/284744/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/ppi-medical-record-review-dispute-request-form/284744.png","ImageObject",442,249,{"name":42,"@type":43},"Valentina","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",23,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information must be attached to this form?","Question",{"text":63,"@type":64},"You must attach a formal letter of dispute, the original Medical Record Review Initial Findings Letter, and any additional documentation that supports your specific dispute.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How should multiple claims be submitted for dispute?",{"text":68,"@type":64},"If you need to dispute multiple claims, the form specifies that they must be mailed or faxed separately to ensure they are routed appropriately.",{"name":70,"@type":61,"acceptedAnswer":71},"What policy types are covered by this dispute form?",{"text":72,"@type":64},"The form covers disputes involving Medicaid, Medicare, and Commercial health insurance policies.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},284744,1790175659,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":4},13056703020460,"https://ap-avatar.wpscdn.com/avatar/be000253dac470eee5d?_k=1778207105932848923","Provider Payment Integrity (PPI)  \nMedical Record Review Dispute Request Form  \nPlease complete and attach this form to your formal letter of dispute to ensure your documentation is routed appropriately. Be sure to include the original Medical Record Review Initial Findings Letter and any other documentation that supports your dispute.  \nHealthcare provider’s name:   State of practice:    \nHealthcare provider’s address:    \n\n| 1. Please indicate the type of dispute:  Review findings  Claim payment If this is a payment dispute, please note the amount being disputed: $  Has this amount been previously disputed?  Yes  No |  |  |\n| --- | --- | --- |\n| 2. What Humana claim number do you wish to dispute?   Note: If you wish to dispute multiple claims, please mail or fax them separately. |  |  |\n| 3. Is the disputed claim a corrected claim?  Yes  No\u003Cbr>If yes, what is the original billed claim number?   |  |  |\n| 4. What level of dispute is this (if applicable)?  1  2 |  |  |\n| 5. What type of policy does this dispute involve? |  Medicaid  | Medicare  Commercial |\n| 6. Are you a participating (contracted) or nonparticipating (noncontracted) healthcare professional?  Participating  Nonparticipating |  |  |\n| 7. Patient’s name: |  |  |\n| 8. Patient’s account number: |  |  |\n| 9. Medicaid ID number: |  |  |\n| 10. Patient’s date of birth: |  |  |\n| 11. Date(s) of service on claim: |  |  |","cbCailUyVv4hnblC","https://ap.wps.com/l/cbCailUyVv4hnblC","pdf",110574,"English","# Medical Record Review Dispute Request Form\n## Provider and Dispute Information\n## Claim and Patient Details","[{\"question\":\"What information must be attached to this form?\",\"answer\":\"You must attach a formal letter of dispute, the original Medical Record Review Initial Findings Letter, and any additional documentation that supports your specific dispute.\"},{\"question\":\"How should multiple claims be submitted for dispute?\",\"answer\":\"If you need to dispute multiple claims, the form specifies that they must be mailed or faxed separately to ensure they are routed appropriately.\"},{\"question\":\"What policy types are covered by this dispute form?\",\"answer\":\"The form covers disputes involving Medicaid, Medicare, and Commercial health insurance policies.\"}]","PPI Medical Record Review Dispute Request Form | PDF",1789629099]