Section 1011 Dispute Resolution Request Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Section 1011 Dispute Resolution Request Form. This is a Official Federal Forms form and can be use in Centers For Medicare And Medicaid Services.
Loading PDF...
Tags: Section 1011 Dispute Resolution Request, CMS-20042, Official Federal Forms Centers For Medicare And Medicaid Services,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
SECTION 1011 DISpuTE RESOLuTION REquEST
DIRECTIONS: If you wish to request a dispute resolution on a payment request determination, please fill out this
form and mail it, along with documentation, to:
Highmark Medicare Services
Attn: Section 1011
P.O. Box 890121
Camp Hill, PA 17089-0121
NOTE: Failure to complete ALL the data elements on this form and/or failure to submit the necessary documentation
will result in your request for a dispute resolution being dismissed. Disputes must be submitted no later than 45 days
after the quarterly payment date for the quarter in which the disputed payment request was billed.
PROVIDER NAME
SECTION 1011 PROVIDER IDENTIFICATION NUMBER (PIN)
PATIENT IDENTIFIER NUMBER (HIC)
DOCUMENT CONTROL NUMBER (DCN)
FULL DATE RANGE OF SERVICE
SPECIFIC DATE(S) OF ITEMS IN DISPUTE
ORIGINAL AMOUNT SUBMITTED FOR REIMBURSEMENT
DENIED SERVICE AND REASON FOR DISPUTE
REQUESTER’S NAME
TITLE
REQUESTER’S E-MAIL ADDRESS
REQUESTER’S MAILING ADDRESS
CITY
STATE
ZIP CODE
REQUESTER’S TELEPHONE NUMBER (INCLUDE AREA CODE)
REQUESTER’S SIGNATURE
DATE SIGNED
All documentation regarding dispute is attached.
Letter of representation is attached (if requester is an entity other than the provider).
Please note that Highmark Medicare Services will not send an acknowledgment of receipt and providers may not
appeal finalized disputes. Highmark Medicare Services will notify providers of decisions via e-mail.
Form CMS-20042 11/10
American LegalNet, Inc.
www.FormsWorkFlow.com