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