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Ucare Appeal Form
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...
Show details
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