Read 48202.pdf text version

HealthPartners Medical Claim Attachment Cover Form

Attachments to claims submitted electronically to HealthPartners can be submitted by mail, fax or via the web. Use this cover form for attachments submitted by mail or fax. Mail form and attachment to: HealthPartners Medical Claims PO Box 1289 Minneapolis, MN 55440-1289 Complete this section for each attachment. Fax form and attachment to: (952) 853-8860 This fax number is only for attachments.

Attachment Control ID:

You assign unique ID for each attachment and submit this ID on your electronic claim

Billing Entity TIN:

Type II NPI is also acceptable

Patient Name:

Clinic Name:

last

first

middle

HealthPartners Member ID:

Date Attachment Sent: Total # Pages for Attachment:

Including this cover form

Clinic Contact:

(name and phone #)

Clinic Fax Number #:

Property & Casualty Claim #:

Disclaimer: For more information on electronic claims submissions, copies of this form, or to upload your attachment directly, visit http://www.healthpartners.com/provider.

5/10

Information

1 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

999345


You might also be interested in

BETA