The Minnesota Request For Certification of Dispute (also known as Form MDH-11) is a document used to certify that a dispute exists between a healthcare provider and a patient or their insurance company. It serves as a form of proof that a dispute has taken place and is used in the case of a third-party payer’s review. The form can be used to certify any type of dispute regarding an unpaid healthcare claim, including medical necessity, coding, coverage, and other issues. The form must be completed and signed by the healthcare provider, the patient (or their representative), and the third-party payer. There are two types of Minnesota Request For Certification of Dispute: MDH-11A and MDH-11B. MDH-11A is used for disputes between a healthcare provider and an insurance company. On this form, the healthcare provider must provide a detailed description of the dispute, including the dates of service, codes for services rendered, and the amount of money in dispute. MDH-11B is used for disputes between a healthcare provider and a patient. On this form, the healthcare provider must provide a detailed description of the dispute, including the dates of service, codes for services rendered, and a breakdown of charges.