Appeal a Claim

When should I use this form?

• To submit a question about a claim or your coverage
  
• To submit information requested by UnitedHealthcare
• To file an appeal or complaint regarding a claim, coverage determination or service received.

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• Enter the information specific to yourself, as the person completing the form. This person may or may not be the person who received medical services. Please remember to also complete the Authorization For The Use and Disclosure of Information form if you are not the patient, enrollee, parent/legal guardian, or provider of service.

• The items to be completed in this section can be found on your Explanation of Benefits received from UnitedHealthcare after your claim was processed or from your Medical ID card. Understanding your EOB
• The subscriber ID is a 9-digit number.
• The group number is a 5-7 character number.
• Demographic information such as your address cannot be updated via submission of this form. To change your address, please contact your company's Benefits Coordinator, who will forward your new information to UnitedHealthcare.

• Check the box that best describes your reason for the submission.
• If you are disputing a decision made by UnitedHealthcare regarding the handling of a claim or coverage for a health service, please include additional comments to explain your request or situation. You may attach additional pages as necessary.

• Complete and submit only the form, page 2 of the document. Keep the instruction page for your records as well a copy of the completed form.
• If your request is related to the handling of a claim, attach a copy of your Explanation of Benefits for each claim, if available. You may obtain a copy of your Explanation of Benefits online by accessing Claims & Accounts and selecting the More Details link on an individual claim on the Medical Claims Summary page.
• If you are submitting additional information requested by UnitedHealthcare, please attach a copy of the letter received requesting this information, if available.
• If you have other documentation or items that may help us understand your request or better explain your situation, please attach these items also.
• If your group number is 192744, 194422, 197313, 229050, 393476, 401010, 503777, 707997, 722266, 722267, 722268, 722269, 722270, or 722271, mail the form with any attachments to:
  
  
  UnitedHealthcare Member Inquiry/Appeals
  PO Box 740816
  Atlanta, GA 30374-0816
  
  
  
• All other group numbers, mail the form with any related attachments to:
  
  
  UnitedHealthcare Member Inquiry/Appeals
  PO Box 30432
  Salt Lake City, UT 84130-0432
  
  
  
• You will receive a written response to your submission within the timeframe required by law.

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