Fillable UMR Post-Service Provider Request Form (UMR)

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UMR Post-Service Provider Request Form (UMR)

On average this form takes 4 minutes to complete

The UMR Post-Service Provider Request Form (UMR) form is 1 page long and contains:

  • 0 signatures
  • 2 check-boxes
  • 17 other fields

Country of origin: US
File type: PDF

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UMR Post-Service Provider Request Form
Please fill out the below information when you are requesting a review of an adverse benefit
determination or claim denial by UMR. Click here
to log in and submit your completed form
electronically (This feature requires Internet Explorer, versions 8 and later. It does not support
Google Chrome or Firefox).
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. Are you including medical records with your request? Yes No
Please note: If no medical documentation is submitted, our review will be based on the
information we currently have on file. Medical records consist of office notes, laboratory
results, operative notes/reports and medical history.
12. Name, address and phone number of person filling out the form
for UMR to contact with any questions:
Name: ______________________________ Address: ______________________________
Company name: _____________________ ______________________________
Phone number: ______________________ ______________________________
13. Description of dispute:
Please fax or mail your completed form along with any supporting medical documentation to the
address listed below.
Fax: 877-291-3248
(Each fax will be reviewed in
the order it is received by the
Appeals Department)
UMR – Claim Appeals
PO Box 30546
Salt Lake City, UT 84130 – 0546
UMC 0033 0820
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UMR Post-Service Provider Request Form (UMR)

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Completed 2 January 2022

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