Sign in to check the status of your claim adjustment and appeal requests. Select “Claim adjustments and appeals” from your menu.

• Add new data or change originally submitted data on a claim
  • Claim adjustment requests – online
  • Claim adjustment request – fax (PDF)
• Reconsideration of originally submitted claim data
  • Claim appeal requests – online
  • Claim appeal form – fax (PDF)
  • Restricted recipient program ER claim reconsideration/appeal – online
  • Restricted recipient program ER claim reconsideration/appeal (PDF)
• Claim attachment submissions
  • Claim attachment submissions – online
  • Dental claim attachment – fax (PDF)
  • Medical claim attachment – fax (PDF)
• Claim correspondence – online

• Annual interpreter services roster (XLSX)
• Credentialing submission
  • Check the status of a new credentialing application
  • Minnesota uniform credentialing application (PDF)
  • MTM credentialing application
  • Initial dental credentialing application (PDF)
  • Minnesota uniform practitioner change form (PDF)
• Disclosure of ownership and management information (PDF)
• Join our network
• New site location request form (DOCM)
• Offshore attestation form (PDF)
• Out-of-network/national medical and dental provider updates (PDF)
• Universal consultant confidentiality agreement (PDF)
  

• Disease, case and lifestyle management
• Hospital admission/discharge (PDF)
• Hospice communication form (PDF)
• Minnesota rare disease intake form
• Network adequacy request – benefit review form (PDF)
• Never event reporting (PDF)
• Restricted recipient program (RRP) provider referral (PDF)
• Self-reported complaints (PDF)
  

Sign in to check the status of your prior authorization request and select “Authorizations and referrals” from your menu.

• Acute rehabilitation facility admission review (PDF)
• Airway clearance system/chest compression generator system review (PDF)
• Balloon sinuplasty review (PDF)
• Continuous passive motion (CPM) review (PDF)
• CFSS technical change request (PDF)
• Deep brain stimulation review (PDF)
• DHS nursing facility (NF) communication form DHS-4461 (PDF)
• Durable medical equipment (DME) review (PDF)
• Enteral nutrition (formula) review (PDF)
• Enteral nutrition (formula) review – Minnesota health care programs (PDF)
• Fixed wing air ambulance transportation review (PDF)
• Genetic testing review (PDF)
• Home health care review (PDF)
• Hospital bed review (PDF)
• Long-term acute care (LTACH) facility admission review (PDF)
• Medical-dental procedures – accidental dental review (PDF)
• Medical-dental procedures – facility-general anesthesia review (PDF)
• Medical-dental procedures – oral surgery for dental conditions review (PDF)
• Medical-dental procedures – orthognathic surgery review (PDF)
• Medical-dental procedures – surgical intervention for TMD review (PDF)
• Medical gender services/surgery review (PDF)
• Mental health partial hospitalization review (PDF)
• Mental health residential treatment services review (PDF)
• PCA assessment review (PDF)
• Phrenic nerve review (PDF)
• Pneumatic compression devices review (PDF)
• Procedures and surgery review (PDF)
• Radiofrequency ablation spine review (PDF)
• Sacroiliac (SI) injections to treat SI joint pain review (PDF)
• Seat lift mechanism review (PDF)
• Site of service-attended polysomnography for evaluation of OSA review (PDF)
• Skilled nursing facility review form (PDF)
• Specialty mattress group I or group II review (PDF)
• Spinal cord stimulator review (PDF)
• Spinal fusion-lumbar review (PDF)
• Substance use disorder services review (PDF)
• Transcranial magnetic stimulation review (PDF)
• Transplant prior notification review (PDF)
• Urine drug testing review (PDF)
• Upper airway, hypoglossal nerve stimulation therapy for obstructive sleep apnea review (PDF)
• Varicose vein procedures of the lower extremities review (PDF)
• Weight loss surgery review (PDF)
• Wheelchair/mobility assistive equipment (MAE) review (PDF)
  

• Accidental dental authorization form (PDF)
• Clinic address change form (PDF)
• Clinic legal or marketing name change form (PDF)
• Initial dental credentialing application (PDF)
• Dental provider change notice (PDF)
• W-9 form for tax ID changes (PDF)
• Prior notification of diabetes or pregnancy (PDF)
  

• Cell and gene attestation form – hemophilia A (PDF)
• Cell and gene attestation form – hemophilia B (PDF)
• Cell and gene attestation – sickle cell (PDF)
• CMS standard format/CCD creator
• Disease, case and lifestyle management
• MTM credentialing application
• New drug request (PDF)
• Prior authorizations and exceptions
  • Prior authorization/exception – online
  • Minnesota uniform prior authorization and formulary exception (PDF)
  • Prior authorization/exception – fax (PDF)