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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



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Attach the supporting documentation for services

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  • 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