UMR Post-Service Appeal Request Form
Please fill out the below information when you are requesting a review of an adverse benefit
determination or claim denial by UMR. If you are appealing on behalf of someone else, please
also include the Designation of Authorized Representative form with this request.
1. Today’s date:
6. Plan name:
2. Patient name:
7. Date of service of claim:
3. Patient date of birth:
8. Claim control number:
4. Member ID:
9. Total billed amount of claim:
5. Member name:
10. Provider name:
11. Does the document contain medical records requested by UMR? Yes No
Please note: If no medical documentation is submitted, our review will be based on the
information we currently have on file.
12. Name, address and phone number of person filling out the form
for UMR to contact with any questions:
Name: ______________________________ Address: ______________________________
Phone number: ______________________ ______________________________
______________________________
13. Description of dispute:
Please fax or mail your completed form along with any supporting medical documentation to the
address listed below.
Fax: 877-291-3248 UMR – Claim Appeals
PO Box 30546
Salt Lake City, UT 84130 – 0546
(Each fax will be reviewed in
the order it is received by the
