Select "Electronically" to submit this form directly to Hennepin Health.  You will be required to attach all supporting documents to this form.

Select "Mail/Fax" if you need to print this form and mail or fax the form and supporting documents to Hennepin Health.

Please note that the timely filling of a claim adjustment/reconsideration request is 180 days from the paid/denied date.

Questions?  Please call Hennepin Health's Provider Services Team at 612-596-1036, option 2.

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

      Validating PMI number . . .

Supporting documentation

Required:  Click the attach button to add up to 20 documents.  You may select multiple files at once, or click the attach button again to add additional files.

Allowed files include images, PDFs and Word documents. 

    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 the 'View/Print PDF' button.  The PDF may automatically download depending on your browser's settings.

    Before you submit:  Check all required fields and validate the member ID and member DOB are for the correct member.

    Click the 'Submit' button to submit this form and supporting documentation to Hennepin Health Customer Services.

    If you attached a large number of documents or documents large in size, it may take a few minutes to complete your submission.  Please let this page continue processing.  When complete, you will receive a 'Thank you' confirmation page.