Please note that the timely filling of a claim adjustment/reconsideration request is 180 days from the paid/denied date.
Please do not use this form to request the following:
Recoupments. A recoupment should be submitted electronically as a voided claim. For "837I" claim types, the last digit of the Type of Bill should end in "8". For the "837P" claim types, the claim frequency code should be "8". The claim number being voided must be included in the claim submission.
Coordination-of-benefits (COB). All COB should be submitted electronically as replacement claims. For "837I" claim types, the last digit of the Type of Bill should end in "7". For "837P" claim types, the claim frequency code should be "7". The claim number being replaced must be included in the claim submission.
Member appeal/grievances. If this is for an appeal on behalf of the member, please use the Member Appeals and Grievances form: www.hennepinhealth.org/-/media/hh/members/Forms/appeals-grievance-form.pdf
Billing Provider Information
Claim Information
Reason for Request
Supporting Documentation
Questions?
Please call Hennepin Health's Provider Services Team at 612-596-1036, option 2.
Please fax or mail to: Hennepin Health Attention: Customer Services 300 South Sixth Street MC 604 Minneapolis, MN 55487-0604
Fax: 612-321-3786
All required fields must be entered prior to clicking on 'View/Print PDF' to create a PDF. The PDF may automatically download depending on your browser's settings.