Restricted Recipient Program (RRP) ER Claim Reconsideration Request Form

This form is for provider use only regarding Emergency Room Reconsideration requests for Restricted Recipient patients.

Please allow up to 7-14 days for us to review this request. Please note that if you need a copy of the completed form, use the paper form submission – you won’t receive a copy of this form entry when you submit it.

For questions regarding ER claim reconsideration requests, please contact the HealthPartners Restricted Recipient Case Management Team at (952) 883-6799. You can leave a voicemail on this confidential line, and your call will be returned within one business day. Please include the member's ID and date of service you're calling about.

For guidance on other common claims scenarios, see our Quick Claim Submission Guide.

All fields are required.

Submission Date

Provider Information:

Provider name

NPI

Tax ID

Contact information:

First name

Last name

Phone number

Ext. (optional)

Fax number

Claim information:

Member first name

MI (optional)

Member last name

Member number

Claim number

Date of service

Billed charges

Supporting information:

Attach documentation to support your request

Description of request (optional)

Please allow up to 7-14 days for this request to be reviewed.

For questions regarding submitted ER claim reconsideration requests, please contact the HealthPartners Restricted Recipient Case Management team at (952) 883-6799. You can leave a voicemail on this confidential line, and your call will be returned within one business day. Please include the member's ID and date of service you're calling about.