Claim correspondence

This form may be used to submit general correspondence such as:

Non-Minnesota Providers
  • Requested information
  • Claim attachments
  • Appeals/adjustments
Minnesota Providers

Provider information

*

Contact information

Claim information

$

Correspondence

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
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Less than one Megabyte attached (Maximum 20MB) {{totalAttachLength | number:2}} Megabytes attached (Maximum 20MB)
  • bmp (Bitmap-image file)
  • csv (Comma-delimited data/spreadsheet)
  • doc
  • docx
  • gif (Image file)
  • jpeg (Image file)
  • jpg (Image file)
  • odt (OpenDocument text file)
  • pdf
  • png (Image file)
  • psd (Photoshop image file)
  • rtf (Text file)
  • tif (Image file)
  • tiff (Image file)
  • txt
  • xls
  • xlsx
  • xml (Data file)
  • xps