ProviderClaimsActionForm

Provider Claims Action Request: Please fill out the form and click Submit Form

Please use this form to request the reconsideration of a claim. If you are not satisfied, an appeal must be filed within one year of the date that UHA first informed you of the denial or limitation of the claim or coverage for any requested service.

Member Information

Patient First Name: Patient Middle Name: Patient Last Name:

Patient Date of Birth:

UHA Member ID#:

Date(s) of Service:

Provider Information

Rendering Physician/Provider

NPI:

Provider Group or Company

Tax ID Number:

Provider Billing Address

If it is determined that money is owed to UHA:

Please withhold funds from future payment(s) We will remit refund to UHA

Contact Person for this Request:

Phone Number:

Contact Email Address:

Fax:

Claim Information

UHA Claim Number:

Issue(s) to be resolved (please check all that apply):

Denied Claim/Claim Line

Incorrect Payment Amount/Payment Error

Coordination of Benefits

Eligibility

Adjustment of Previous Billed Claim

Other (Please Describe Below)

Please explain the reason for this request:

0 / 8000 characters used

Upload Supporting Documents

Please upload any supporting documents.

The maximum file size for uploads is 2 MB per file.

Allowed file types: PDF, JPEG, GIF, BMP, TIFF and PNG

Choose File then click Upload File.

Upload File

List of Uploaded Files:
None.

By checking this box I affirm that I am authorized on behalf of my organization to submit this form. I have used all reasonable diligence in submitting the information in this form, and I certify that the information submitted is corrrect.
The parties agree that this form and all notices and disclosures made or given in connection with this form may be created, executed, delivered and retained electronically. As such, the parties agree that this form and any related documents may be signed electronically, and that the electronic signatures appearing on ths form or any related documents shall have the same legal effect for all purposes, including validity, enforceability and admissibility, as a handwritten signature.
By signing and submitting this form, Provider confirms the accuracy and completeness of the information provided on this form and any attachments, and agrees to be bound by the terms of the UHA Participating Provider Agreement and UHA’s Provider Handbook, which terms shall become effective upon UHA sending a letter giving Provider notice of approval of addition. Provider also confirms his/her intent to be bound by the dispute resolution process described in UHA’s Participating Provider Agreement, described above, which includes binding arbitration of all disputes.