Regence Pricing Dispute Form

Use this form to disagree with our decision on how a claim processed according to your provider agreement.

Important notes:

  • Pricing disputes are not appeals and do not follow the appeal process or timeline.
  • Any dispute or appeal that is not a pricing dispute and/or is from a non-contracted provider will be returned to follow the appropriate appeal process.
  • Appeals will not be forwarded using this submission channel.

Before submitting this form:

We require you to validate your pricing dispute using all available resources, including but not limited to:

  • Your reimbursement schedule
  • Your most recent agreement terms
  • Provider website resources, including:
  • Provider Contact Center
  • Availity Essentials resources

    • Facility diagnosis related group (DRG) pricing is applied per the grouper version indicated in your agreement. Please verify your current grouper version matches what is indicated in your agreement prior to submitting a DRG dispute.

    Fields marked with an asterisk (*) are required fields.

    Your details

    		     
    First name:* Last name:*
    Phone:* Email:*
    NPI number:* Tax ID number:*
    Rendering Provider/Facility name(s):* Fax number:
    Contract ID: The Contract ID is found in the footer of your agreement document.

    Are you a third-party billing company?*
    		 

     

     

    If yes, complete the following.

    		 Billing company name: Requestor’s department: Requestor’s direct phone:
    Are you the provider's business associate?*

    If yes, explain the work you do on behalf of the provider:

    Claim details

    		 
    Has this claim been disputed with Regence before?*
    Does this dispute impact more than five Regence members:*
    Claim number(s):*

    Add up to five claim details in the following fields, separated by a comma.
    Dates of service:*
    Member ID number(s) (include prefix/member ID):*
    Member name(s):*
    Member date(s) of birth:* (e.g., 01141969)
    Patient account #(s):
    Total billed amount (s):*

    Pricing dispute details

    		 
     

    Please provide a detailed explanation:*

    Documentation*

    • If documentation examples are not included in support of this pricing dispute, this request will be considered invalid and will be returned without review. Please complete all applicable fields below. If a specific field is not applicable, it can be left blank.

    Regence provider website:

    • Include description and URL of content:

    Specific agreement terms:

    • Include agreement name, effective date and page number, as well as the rationale being used for the dispute, such as RVU year, base rate, conversion factor, percentage, etc.

    Administrative Manual:

    • Include the manual section and page number

    Reimbursement schedules:

    • Include schedule name, effective date and page number

    Reimbursement policy:

    • Include policy name and number or website link.
    Desired outcome and expected additional payment amount:*
       
     

    We process updates within 30 business days.

    If you have questions after 30 days, please call the Provider Contact Center.

    Please DO NOT submit duplicate requests.