Claim attachment

Our website no longer supports Internet Explorer. For the best browsing experience, we recommend using Chrome, Safari, Edge or Firefox.

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.

Provider information

* Provider name

* Tax ID NPI

Contact information

* First name

* Last name

* Email

* Phone #

Ext.

Claim information

* Product type

HealthPartners Commercial products HealthPartners Government and Senior products HealthPartners Dental

* Member first name

* Member last name

* Member #

Claim #

Attachment information

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.

Attach the supporting documentation for services

* Attachment control ID

{{attachment.controlId}} - {{attachment.filename}}

Less than one Megabyte attached (Maximum 20MB) {{totalAttachLength | number:2}} Megabytes attached (Maximum 20MB)

Comments