Fillable Appeal Request Form printable pdf download

Appeal Request Form

Instructions: This form is to be completed by Home and Community based Providers, Skilled Nursing Facilities, Physicians,

Hospitals ,or other Health Care Professionals requesting an appeal regarding services rendered to an UnitedHealthcare

Community Plan product enrollee.

Date_______________

[ ] Home and Community based Providers [ ]Skilled Nursing Facility

[

] Physician [ ] Hospital [

] Other Health Care Professional (Lab, DME, etc)

___________________________________________________________________________________________________________

Subsequent Submission (Appeal Request) – As a “Subsequent Submission” this request will be handled as an Appeal and all pertinent

information to support the appeal should be attached. Send all Appeal requests to:

UnitedHealthcare Community Plan

P.O. Box 31364

Salt Lake City, UT 841310364

(NOTE: It is required that you complete the Claim Reconsideration process before you submit this Appeal Request form. The Appeal

is the final stage of internal dispute resolution.)

ENROLLEE INFORMATION

Enrollee Name: __________________________________________________________________D.O.B. ______________________

Control / Claim #: ____________________________________ D.O.S.___________________________

Billed Amount _____________________ Enrollee ID #: ____________________________________________________

PHYSICIAN/HEALTH CARE PROFESSIONAL INFORMATION

Tax Identification Number: ___________________________________________

Physician/Facility Name (as listed on PRA / EOB): _________________________________________________________________

Contact Person: ______________________________________ Phone Number: __________________________________________

REASON FOR REQUEST

[ ] 1. Previously denied as “Exceeds Filing Time” (attach valid proof of timely filing, computer generated activity or print screen,

EOB statement or letter from another insurance carrier which proves claims were filed timely)

[ ] 2. Previously processed, rate applied incorrectly resulting in over/underpayment (explain below)

[ ] 3. Previously processed as “Bundled claim” (including all supporting information)

[ ] 4. Other (explain below) Comments:

Required Attachments:

• Copy of Provider Remittance Advice (PRA) or EOB

• Claim form (with corrections if necessary)

• Other required attachments as listed above

NO NEW CLAIMS SHOULD BE SUBMITTED WITH THIS FORM. SUBMIT A SEPARATE FORM FOR EACH CLAIM

This form is intended to be used to seek review of claims for services provided to website product enrollees. For review of members

enrolled in other benefit plans, please refer to one or more of the following for information on requesting claim reviews: the website

for the entity listed on the member's identification card, the Explanation of Benefits for the applicable claim, or

You may also call the telephone number on the member's identification card for information on

how to request claims reviews.

For questions related to the status of Appeals over 30 days please refer to the Customer Service phone number listed in the

Provider Administrative Manual or at .

M50644 1/12 Revision date: 4/3/12

This document is proprietary and confidential

Appeal Request Form

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