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WebGet the free Participating Provider Claims Dispute Form - MDwise Hoosier Alliance - hoosieralliance Description PARTICIPATING PROVIDER CLAIMS DISPUTE FORM Provider Name: Telephone: Fax: Date of Service: Member Name: Member RID#: Disputed Service(s): Form completed by: Date: Describe the disputed claim. Web2024 IHCP Annual Workshop MDwise Claims Providing health coverage to Indiana families since 1994 WebEach MCO is required to maintain a Provider Complaint System for in-network and out-of-network providers to dispute the health plan’s policies, procedures, or any aspect of the plan’s administrative functions. Providers should first seek resolution with the MCO, using the MCO contacts outlined below. family nurse practitioner jobs philadelphia