8/22/2024
Claim Appeal Form
For Claims Adjustments, see the online or fax Claim Adjustment Request form.
Sign in to check the status of your claim adjustment and appeal requests. Select Claim
Adjustments and Appeals from your menu.
Claim Appeal requests include reconsideration of an adjudicated claim where the originally submitted data is accurate or
a claim that was denied for timely filing. A HealthPartners claim number is required.
Patient Member Number _______________________ Patient Name_____________________________________
HealthPartners Claim Number_______________________________
First Date of Service ______________________________ Billed Amount $________________________________
Provider Name ________________________________________________________________________________
Billing Provider ID# NPI (preferred) or Tax ID_________________________________________________________
Contact Person ______________________________ Phone# ___________________________________________
Fax# (Required) ____________________________________
Please check applicable reason and attach supporting documentation. A description of the request is
REQUIRED.
TIMELY FILING/Late
Claims Submission
REQUEST MUST BE MADE WITHIN 60 DAYS OF THE ORIGINAL DISALLOWED
CLAIM.
Check this box to appeal claims submitted after your contractual filing limits. 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.
Pricing
Incorrect payment or application of benefits
Eligibility Issues
Payment related to member eligibility
Coding Review
Appeal of coding decision. Supporting documentation is required
Prior Authorization
Denied for No Prior Authorization.
Request for medical necessity review for claim(s) Check appropriate review type:
Medical Policy Medical Injectable/IV’s Behavioral Health Dental
Credentialing
Professional credential information was incorrect or has been updated since claim
processed
Other
Detailed description REQUIRED below
Complete Description of Reason for Claim Appeal:
Commercial Insured Products
PO Box 21024
Eagan, MN 55121
952-883-7770 or 7755
Fax 651-265-1230
Government and Senior Products
PO Box 21662
Eagan, MN 55121
952-883-7699//888-663-6464
Fax 952-883-7666
HealthPartners
Dental Products
PO Box 211532
Eagan, MN 55121
952-883-5165//800-642-1323
Fax 952-883-5160
8/22/2024
