Washington Self-Insurance Medical Provider Billing Dispute Form is a document used by medical providers in Washington State to dispute payments received from self-insured health plans. This form can be used to dispute payment amounts, denials, or other issues related to a provider's billing. There are two types of Washington Self-Insurance Medical Provider Billing Dispute Forms: • Standard Dispute For— – This form is used to dispute a payment amount, denial, or other issue related to a provider’s billing. This form must be completed in full and include supporting documents such as a copy of the claim and any explanation of benefits. • Expedited Dispute For— – This form is used to expedite the dispute process. It must be completed in full and include supporting documents such as a copy of the claim and any explanation of benefits. It must be submitted within 10 business days of receipt of the payment or denial.
Washington Self-Insurance Medical Provider Billing Dispute Form
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How to fill out Washington Self-Insurance Medical Provider Billing Dispute Form?
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Billing Assistance For bill underpayment disputes only complete and submit the Self-Insurance Medical Provider Billing Dispute form (F207-207-000), or call L&I's Self-Insurance Section at 360-902-6938.
You can also contact support directly with questions by calling 877-255-5923. If you close your Apple Card account, information about your Apple Card account will remain in Wallet until you remove Apple Card from the Wallet app.
Online via our FileFast tool. By phone: 1-877-561-FILE (3453) At your doctor's office (if you complete the Report of Accident at your doctor's office, the doctor files the form for you)
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