Claim Payment Dispute Request Form for
UnitedHealthcare Medicare Advantage Plan Non-Participating Providers
Following are instructions on how non-participating UnitedHealthcare Medicare Advantage care
providers can dispute a claim payment amount.
Instructions
This form is for non-participating UnitedHealthcare Medicare Advantage care providers who want
to request review of a claim payment for members enrolled in a UnitedHealthcare Medicare Advantage
plan.
•
Submit your request to us within 120 calendar days of your provider remittance advice (PRA)
notification date.
•
Submit this form to the address on your PRA.
•
No new claims should be submitted with this form.
•
Please submit a separate form for each claim payment being disputed.
•
This form is not for appeals. You’ll find information about your appeal process on your PRA.
•
Care providers participating in UnitedHealthcare Medicare Advantage benefit plans can find
information about their claims payment dispute process in
the UnitedHealthcare Administrative
Guide at > Tools & Resources > Policies, Protocols and Guides >
Administrative Guides.
Care Provider Information
Date: ____________________
I am a:
Physician
Hospital/Facility
Other health care professional
Care Provider Name (listed on the PRA): ________________________________________________
Tax Identification Number (TIN): _____________ Phone Number: _____________ Email: ___________
Address: ____________________________________________________________________________
Group/Facility Name (if applicable): _______________________ Contact Name: __________________
Claim and Member Information
Control/Claim Number: _____________ Date of Service: ___________ Billed Amount: _____________
Member Name: ______________________________________________________________________
Member Address: _____________________________________________________________________
Reason for dispute:
Bundling issues
Payment rate
Diagnosis related group
(DRG) payment
Other (please explain in Comments)
Doc#: PCA-1-004310-12012016_01102017
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