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Claim Adjustment / Appeal Request

Claim Adjustment / Appeal Request

Attention Minnesota Providers! If your request will result in changing data on the original claim, you must submit your adjustment electronically (not through provider portal). Use our Quick Claim Submission Guide to review guidelines for common claim scenarios.
Also reference the Minnesota Statute section; 62J.536 requiring MN providers to submit adjusted claims in the electronic 837 format.

* Required Fields
* Product Type
HealthPartners Fully Insured and Self Insured Products
HealthPartners Government Programs Senior/Medicare Products
HealthPartners Dental
 
Provider Information:
* Provider Name: * Billing Provider ID#:  ?Billing Provider ID includes: Payee NPI, Tax id "xx-xxxxxxx", or UMPI
* Your Name: * Phone Number:
 
Contact Information:Same as above
* Contact Person: * Phone Number:
* Contact Email:    Fax Number:
 
Claim/Patient Information:
* Patient Name: * Member Number:
* First Date of Service:    Billed Amount:
* Claim Number:

* Type of Claim Adjustment
Payment Adjustment Claim Appeal
Payment Adjustment requests include additional or corrected data that was not on the original claim. A claim number is required for all payment adjustment requests.

Coordination of Benefits
  Payment information attached (attachment required to submit)
  Amount paid by other insurance 
 
  Patient Responsibility:
  Other Carrier Name:
  Insurance Type: Medicare Group Auto
    Work Comp Dental Other
Duplicate Payment Incorrect Rendering Provider
Incorrect Billing Provider Previously denied authorization has been approved:
Late credit/charge
  Authorization Number:
Charges Billed in Error Unlisted Procedure Description (explain in description)
Item returned Corrected Coding (explain in description)
Other (explain in description)  

Comments/description:
Supporting Documentation:
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