Provider Dispute Resolution Forms

The information and forms provided on this page are for Non- Contracted Providers ONLY. HPSJ contracted providers should sign into DRE for PDR information and submissions.

  • If you are trying to submit corrections on a claim, please follow the Corrected Claim submission guidelines.
  • If a claim was denied as a duplicate and you feel it denied in error, please make sure it was submitted with the appropriate documentation, modifiers or corrected claim submission indicator before you submit a dispute.
  • If a claim or claim line was denied for supporting documentation, please submit as Correspondence with the requested information.

Form Download

Please select the form you would like to download from the following choices:

Appeal of Medical Necessity / Utilization Management Decision
Original claim denied because of a denied authorization or partial authorization.

Contract Dispute
Original claim did not pay per Contract or MCL Rate(s).

Recovery Request Dispute
A letter was received regarding an identified overpayment and you do not agree with the determination.

Requested Correspondence Cover Page
A claim/claim line or PDR denied for additional documentation

Seeking Resolution of a Billing Determination
Use this form if you do not agree with claim and/or claim line denial.

GEMT Supplemental Payment

Non-Contracted Providers ONLY

Providers can request immediate recoupment for overpayments where we issued a demand letter. By using the immediate recoupment process, providers may avoid submitting a check and interest assessments.

You can submit the request for an overpayment(s) related to a specific demand letter or for all future overpayments.

Offset Request Form

Complete this online form to initiate a request for immediate recoupment of overpayment(s).

  • All fields are required, and the form must be completed in its entirety prior to submitting your request.

Posted on October 15th, 2020 and last modified on April 15th, 2024.