Appeal Request Form printable pdf download

Appeal Request Form

Instructions:

This form is to be completed by Physicians, Hospitals, or other health care professionals who wish to request a clinical appeal of an

adverse medical determination or administrative claim made by UnitedHealthcare Community Plan (Do not use this form for Claims

Reconsideration requests).

Are you appealing on the member’s behalf? [ ] Yes [ ] No

(Please note: If you are requesting to appeal on behalf of a Community Plan member enrolled in the MississippiCAN program you must submit

written consent from the member with this request).

Today’s Date: ________________________ I am a: [ ] Physician [ ] Hospital [ ] Other Health Care Professional/Service (APRN, DME

company, etc.)

Date(s) of Service being appealed ____________________________________________________________________________________________

PLEASE SEND A COPY OF ALL ADMINISTRATIVE OR MEDICAL RECORDS PERTINENT TO THE EPISODE OF CARE FOR WHICH THE ADVERSE

DETERMINATION WAS MADE WITH THIS FORM – THIS INFORMATION IS CRITICAL TO YOUR APPEAL REVIEW.

________________________________________________________________________________________________________________________

NOTE: MAIL (No Faxes) Appeal Request Form AND All Pertinent Records concerning the episode of care being appealed to:

UnitedHealthcare

ATTN: APPEALS

P.O. Box 5032

Kingston, NY 12402-5032

PATIENT’S INFORMATION (Please Print):

Patient Name: __________________________________________________________________ D.O.B.:___________________________________

UnitedHealthcare Community Plan ID #: ________________________________ Medicaid ID #: __________________________________________

PHYSICIAN/HEALTH CARE PROFESSIONAL/FACILITY INFORMATION (Please Print):

Tax Identification Number: _________________________________________________________________________________________________

Physician / Provider/ Facility Name: _____________________________________________________ NPI #:________________________________

Practice Contact Person: ___________________________________________________________________________________________________

Fax #: ___________________________________________________ Phone #: ________________________________________________________

REASON FOR REQUEST

[ ] The denial or limited authorization of a clinical service

[ ] The reduction, suspension, or termination of a previously authorized clinical service

[ ] The denial, in whole or in part, of payment for a service

[ ] Other (Please Print):

_______________________________________________________________________________________________________________________________________

To check on the status of an Appeal, please call Provider Services: 877-743-8734

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

Appeal Request Form