UHC1060b.1_20121221
UnitedHealthcare Single Claim Reconsideration Request Form
This form is to be completed by physicians, hospitals or other health care professionals to request a claim reconsideration for
members enrolled in benefit plans administered by UnitedHealthcare.
NOTE: Please submit a separate claim reconsideration request form for each claim reconsideration request
No new claims should be submitted with this form. Do not use this form for formal appeals or disputes. Continue to
use your standard appeals process for formal appeals or disputes.
Please refer to the Claim Reconsideration cover sheet or your provider administrative manual for additional details including
where to send Claim Reconsideration requests. You may verify the member’s address using the eligibility search function on
the website listed on the member’s health care ID card.
Physician Hospital Other health care professional (Lab, Durable Medical Equipment (DME),etc)
Member information Date form completed:
Member ID:
Control / Claim
#:
Date of Service:
Billed Amount:
Member Last Name
First Name
MI
Street Address
State
Zip
Patient Name: Last
First
MI
Physician/health care professional information
Tax Identification Number (TIN): Phone Number: ( ) Email address:
Physician Name or other health care professional (as listed on Provider Remittance Advice (PRA)/Explanation of Benefits (EOB):
Last Name First MI
Street Address State Zip
Facility/Group Name Contact Person:
Reason for request: (More information on the definition reasons listed below and what documentation needs to be submitted can be found on
the Claim Reconsideration definition sheet located on our website)
1. Previously denied / closed as “Exceeds Filing Time”
2. Previously denied / closed for “Additional Information”
3. Previously denied / closed for “Coordination of Benefits” information
4. Resubmission of a corrected claim
5. Previously processed but rate applied incorrectly resulting in over/underpayment
6. Resubmission of “Prior Notification Information”
7. Resubmission of “Bundled claim”
8. Other (explain below)
Please include what you are expecting from UnitedHealthcare to close UnitedHealthcare’s portion of this claim reconsideration
in your practice management system, including dollar amount if possible
.
Comments:
Required attachments:
Copy of PRA or EOB Claim Form is ONLY required for Corrected Claims Submissions • Other required attachments as listed above
You may have additional rights under individual state laws. For review of claims for 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 health care ID card or the EOB for the applicable claim. You may also call the telephone number on the
member’s health care ID card for information on how to request claims reviews.
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