Claim Adjustment Request Form
* Required Fields
* Product Type:
HealthPartners Fully Insured and Self Insured Products
HealthPartners Government Programs Senior/Medicare Products
HealthPartners Dental
* Provider:		* User Name:
* Phone Number:		* Email:
* Patient Name:		* Member Number:
* First Date of Service:		Billed Amount:
Claim Number:
Provide contact information if different than above:
Contact Person:		Phone Number:
Contact Email:		Fax Number:

Payment Adjustment
Coordination of Benefits
Payment information attached (attachment required to submit)   Amount paid by other insurance      Other Carrier Name:   Insurance Type: Medicare Group Auto     Work Comp Dental Other
Duplicate Payment	Late Credit/Charge
Cannot Identify Patient	Incorrect Member
Charges Billed in Error/Item returned	Professional Fees Not Processed
Paid on Ineligible Charge	No Discount Applied
Incorrect Per Diem/Discount Applied
E1399 Description
Previously denied authorization has been approved:
Authorization Number:

Claim Coding Appeal

Additional Diagnosis:

ADA/CPT code  should be

Tooth #/Surface:

Multiple Modifiers 1)  2)  3)  4)

Operative report/office notes are attached which further explain services provided

Other Coding Issue

Other Appeals
Supporting documentation is required to submit a Late Claim Submission appeal.
HPFIN/HPPID/NPI
Dental License #
Late Claim Submission

Additional Comments:
Supporting Documentation: