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Claim Attachments

This form is limited to the online submission of attachments in support of a claim submitted through the electronic 837 format. All other correspondence will be disregarded.

The related electronic claim must have an attachment indicator and the attachment control number in the PWK segment of the 837 form.

Use our Quick Claim Submission Guide to review guidelines for common claim scenarios.

Step 1 of 2: Claim Information * Required Fields

* Product Type: HealthPartners Fully Insured and Self Insured Products
HealthPartners Government Programs Senior/Medicare Products
HealthPartners Dental
 
* Provider Name: * Billing Provider ID#:  ?Billing Provider ID includes: Payee NPI, Tax id "xx-xxxxxxx", or UMPI
* Contact Person: * Phone Number:
* Patient Name: * Member Number:
* Contact Email:    Claim Number:
Comments/description: