Healthcare Billing Discrepancy Resolution Template
Patient Information
Patient Name
Date of Birth
Patient ID / MRN
Contact Number
Provider & Billing Details
Provider Name
Service Date
Invoice Number
Claim Number
Discrepancy Details
Type of Discrepancy
Duplicate Charge
Incorrect Service/Procedure
Insurance Denial
Service Not Rendered
Coding Error
Other
Description
Action Requested
Resolution Sought
Bill Correction
Claim Re-submission
Refund
Appeal Submission
Other
Additional Comments
Submission Details
Submitted By
Date