Write a letter describing your appeal or use the Redetermination Request Form (PDF) (67.62 KB). Mail or fax the letter or completed form to UnitedHealthcare.

Provider Claim Reconsideration Request Form. Use this form to challenge, appeal or request reconsideration of a claim. Learn more. Provider claim ...

Appeals must be submitted within 30 days of the claim fill date or within such time period as may be required by applicable state law.

The forms below cover requests for exceptions, prior authorizations and appeals. Medicare prescription drug coverage determination request form (PDF) (387.04 KB) ...

Find forms for claim reimbursement, Medicare and Medicaid, prior authorization requests and privacy and confidentiality.

Notes: • Please submit a separate form for each claim. • No new claims should be submitted with this form. • Do not use this form for formal appeals or disputes ...

Coordination of Benefits: The requested review is for a claim that could not fully be processed until information from another insurer has been received.

Expedited appeal requests can be made by phone at: (800) 595-9532. Who May Make a Request: Your prescriber may ask us for an appeal on your behalf. If you ...

Visit the Prior Authorization Page, Provider Portals, expand_more, Submit a Pre-Service Appeal and or Grievance for a Medicaid Member.

Optum Rx claim form to request reimbursement for covered medications purchased at retail cost. *Used only if plan includes Optum Rx benefits (PBM National).