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
400 S. 4th Street
Minneapolis, MN 55415

Fax: 612-321-3786