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Provider appeal for claims

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.

Appeal reason

* Please check applicable reason

Check this box to appeal claims submitted after your contractual filing limits.
  • Appeal must be made within 60 days of original disallowed claim. If you have questions about your filing limit please contact your contracting representative.
  • Attach a copy of the original claim showing the original print date or a screen print from your billing system showing the account activity and the reason why the claim is/was submitted late.

Documentation supporting your appeal is required.

Check this box to appeal claims for incorrect payment or application of benefits.
Check this box to appeal claims for payment related to member eligibility.

Examples include:

  • Payer sequencing
  • Paid ineligible charge
  • Processed under incorrect member

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).

Check this box to appeal claims when professional credential information was incorrect or has been updated since claim processed.

Provider information


Contact information

Claim information


Supporting information

Attach documentation to support your request

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