Provider Guidelines for Filing a Claim Dispute

All claim disputes must be hand-delivered or mailed to:

Division of Developmental Disabilities
Office of Administrative Review
1789 West Jefferson Street
Mail Drop 2HE5
Phoenix, Arizona 85007

Guidelines for Filing a Claim Dispute

• Division Operations Policy Manual Chapter 6000-K Claims Disputes states: “...The claim dispute must be filed within 12 months from the ending date(s) of service, within 12 months of date  the member’s eligibility is posted, within 12 months from the date of discharge from a hospital, or within 60 days after the date of the denial of a timely claim submission,” whichever is latest.
• Claim disputes must be filed in writing include the following factual information:
  
  • PROVIDER AHCCCS ID
  • PROVIDER NAME
  • PROVIDER TIN/SSN
  • WELLSKY CLAIM ID
  • MEMBER AHCCCS ID
  • MEMBER FIRST NAME
  • MEMBER LAST NAME
  • HCPCS CODE/CPT Code
  • DDD SERVICE
  • START DOS
  • END DOS
  • TOTAL UNITS
  • TOTAL AMOUNT BILLED
  • Supporting information for reason/s the claim should be paid
• DDD’s Office of Administrative Review will deny a claim dispute if the factual information is not included.
• Claim disputes must be filed in writing and specify in detail the factual and legal basis for the claim dispute and the relief requested.
• Documentation MUST  be completed in Excel on the Claims Grievance Log.
• Do not include supporting documentation for members not listed on your claim dispute letter.
• Qualified Vendors with a billing inquiry should check the GAO website or their Billing Detail Report in FOCUS. Additional questions can be emailed to DDD Provider Relations. They can also be contacted by phone at 1-844-770-9500 option 1, TTY/TDD 711.

Adjustment Requests

Providers should submit a corrected or voided claim through the WellSky system.