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  • Provider Dispute Claim Reconsideration Request Form

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Provider Dispute Claim Reconsideration Request Form Today 's date Member Information Member last name: First name: Date of birth: Member Identification Number (EIN): Physician/Health care professional.

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You have 1 year from the date of occurrence to file an appeal with the NHP. You will receive a decision in writing within 60 calendar days from the date we receive your appeal.

A "Reconsideration" is defined as a request for review of a prior authorization that a provider feels was incorrectly denied or prior authorized.

UnitedHealthcare's top competitors include Angle Health, Blue Cross Blue Shield, and Devoted Health. Angle Health provides health insurance plans and benefits to members, employers, and brokers. It builds an AI-powered technology platform and regulatory infrastructure.…

You have a limited amount of time to appeal a coverage decision. You'll need to submit your appeal: within 60 days of the date the unfavorable determination was issued or. within 60 days from the date of the denial of reimbursement request.

A Member has the right to request a review of a claim denial. The member or the Designee must send a written request for an appeal within 180 days of the receipt of the Explanation of Benefits to: UnitedHealthcare, P.O. Box 31391, Salt Lake City, UT 84131 or call Customer Service at 1-800-444-6222.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232