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Get UMR Post-Service Appeal Request Form

UMR Post-Service Appeal Request Form Please fill out the below information when you are requesting a review of an adverse benefit determination or claim denial by UMR. 1. Today s date 6. Plan name 2. Patient name 7. Date of service of claim 3. Patient date of birth 8. Claim control number 4. Member ID 9. Total billed amount of claim 5. Member name 10. Provider name 11. Name of person filling out the form Phone number 12. Description of dispute Please fax or mail your completed form along with any supporting medical documentation to the address listed below. Please note If no medical documentation is submitted our review will be based on the information we currently have on file. Fax 877-291-3248 UMR Claim Appeals PO Box 30546 Salt Lake City UT 84130 0546 877-805-1990 T www. UMR*com. Today s date 6. Plan name 2. Patient name 7. Date of service of claim 3. Patient date of birth 8. Claim control number 4. Member ID 9. Total billed amount of claim 5. Member name 10. Provider name 11. Name of person filling out the form Phone number 12. Member ID 9. Total billed amount of claim 5. Member name 10. Provider name 11. Name of person filling out the form Phone number 12. Description of dispute Please fax or mail your completed form along with any supporting medical documentation to the address listed below. Description of dispute Please fax or mail your completed form along with any supporting medical documentation to the address listed below. Please note If no medical documentation is submitted our review will be based on the information we currently have on file. Please note If no medical documentation is submitted our review will be based on the information we currently have on file. Fax 877-291-3248 UMR Claim Appeals PO Box 30546 Salt Lake City UT 84130 0546 877-805-1990 T www. UMR*com. Today s date 6. Plan name 2. Patient name 7. Date of service of claim 3. Patient date of birth 8. Claim control number 4. Member ID 9. Total billed amount of claim 5. Member name 10. Provider name 11. Name of person filling out the form Phone number 12. Description of dispute Please fax or mail your completed form along with any supporting medical documentation to the address listed below. Member ID 9. Total billed amount of claim 5. Member name 10. Provider name 11. Name of person filling out the form Phone number 12. Description of dispute Please fax or mail your completed form along with any supporting medical documentation to the address listed below. Please note If no medical documentation is submitted our review will be based on the information we currently have on file. Description of dispute Please fax or mail your completed form along with any supporting medical documentation to the address listed below. Please note If no medical documentation is submitted our review will be based on the information we currently have on file. Fax 877-291-3248 UMR Claim Appeals PO Box 30546 Salt Lake City UT 84130 0546 877-805-1990 T www. UMR*com. .

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