Medicaid Expansion Provider Dispute Form

This form is to be used to submit a Provider Dispute. The Provider Complaint system permits the submission of a dispute on BCBSND’s policies, procedures, or any aspect of BCBSND’s administrative functions, including proposed actions, claims/billing disputes, and service authorizations.

 * Required fields


Member Information

Please enter a valid Date.

Provider Information

Submitter Information

*Required Fields

Claims Information

Reference Information

Review

Member First Name : Edit
Member Last Name : Edit
Member Date of Birth : Edit
Member ID Number : Edit
Member Phone Number : Edit
Provider First Name : Edit
Provider Last Name : Edit
Facility Name : Edit
Provider NPI : Edit
Provider Phone Number : Edit
Provider Fax Number : Edit
Address : Edit
Address Line 2 : Edit
City : Edit
State : Edit
ZIP Code : Edit
Submitter First Name : Edit
Submitter Last Name : Edit
Address Line 1 : Edit
Address Line 2 : Edit
City : Edit
State : Edit
ZIP Code : Edit
Phone Number : Edit
Fax Number : Edit

Print this page for your records before submitting the application.