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Ucare Appeal Form

Ucare Appeal Form

Use a ucare appeal application 0 template to make your document workflow more streamlined.

Must be submitted with additional information over and above what was submitted with the initial appeal. *Billing Provider Information Provider Name: UCare Provider#: NPI Number: UMPI Number (if applicable): *Claim Information Member Name: UCare Member Number: 00 - - 00 Date(s) of Service: Claim Number(s): *Reason for Request (see definitions on reverse side) Payment Dispute Timely Eligibility Medical Policy Review Code Review Other Authorization (check appropriate box below) Nursing...
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