This form is for provider use only. If you are a member, please call Member Services at the number on the back of your member ID card, or get information about submitting a member appeal.
Provider appeal reason requests include reconsideration of an adjudicated claim where the originally submitted data is accurate or a claim that was denied for timely filing.
If a claim was denied for LACK of Prior Authorization you must complete the necessary Authorization form, include medical necessity documentation and submit to HealthPartners Quality Utilization and Improvement (QUI) fax: 952-853-8713 or mail: PO Box 1309, 21108T, Minneapolis MN 55440-1309.
To appeal member liability or a denial on patient’s behalf, contact Member Services at the phone number on the patient’s ID card.
Use our Quick Claim Submission Guide to review guidelines for common claim scenarios.
Minnesota Statute section; 62J.536 requires Minnesota providers to submit adjusted claims in the electronic 837 format.
* Please check applicable reason
Documentation supporting your appeal is required.
Examples include:
Check this box to appeal claims for appeal of coding decision.
Documentation supporting your appeal and fax # are required.
Denied for no prior authorization. Request for medical necessity review for claim(s).
* Review type
Attach documentation to support your request
The file/s have been attached and will be submitted with this form, but the attached file names are not available to display at this time.
You may continue and submit this form if you have attached the appropriate documentation, or click cancel to start over.
