[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-286876-105":53,"doc-detail-286876-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","umr-post-service-provider-request-form","UMR Post-Service Provider Request Form","","This document provides the official UMR Post-Service Provider Request Form, which healthcare professionals must utilize to initiate a formal review of an adverse benefit determination or claim denial. The form requires essential clinical and administrative data, including patient demographics, plan details, specific claim identifiers, and total billed amounts. Providers are prompted to include comprehensive medical documentation, such as operative notes and laboratory results, to facilitate an accurate appeals review process. The form outlines clear submission protocols, including electronic options and mailing or faxing procedures directed to the UMR Appeals Department in Salt Lake City. By standardizing the request process, this document ensures that all necessary information is captured, thereby streamlining the internal review cycle and enhancing the communication between providers and the UMR administration for efficient claim resolution and policy compliance.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/umr-post-service-provider-request-form/286876/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/umr-post-service-provider-request-form/286876.png","ImageObject",442,249,{"name":88,"@type":89},"Genevieve","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-19","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What is the purpose of the UMR Post-Service Provider Request Form?","Question",{"text":108,"@type":109},"The form is used by healthcare providers to request a formal review of an adverse benefit determination or a claim denial by UMR.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What documentation should be included with the request?",{"text":113,"@type":109},"Providers should include relevant medical records such as office notes, laboratory results, operative reports, and patient medical history to support the appeal.",{"name":115,"@type":106,"acceptedAnswer":116},"How can a provider submit the completed request form?",{"text":117,"@type":109},"The form can be submitted electronically through the UMR portal or by faxing/mailing the completed document along with medical records to the address and fax number provided on the form.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},286876,1789631646,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":4},1374391974585,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","UMR Post-Service Provider Request Form  \nPlease 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) .  \n\n| 1. Today’s date: | 6. Plan name: |\n| --- | --- |\n| 2. Patient name: | 7. Date of service of claim: |\n| 3. Patient date of birth: | 8. Claim control number: |\n| 4. Member ID: | 9. Total billed amount of claim: |\n| 5. Member name: | 10. Provider name: |\n\n11. 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.  \n12. Name, address and phone number of person filling out the form for UMR to contact with any questions:  \nName:   Address:   Company name:      \nPhone number:  \n______________________ ______________________________  \n13. Description of dispute:  \nPlease fax or mail your completed form along with any supporting medical documentation to the address listed below.  \nFax: 877-291-3248  \n(Each fax will be reviewed in the order it is received by the Appeals Department)  \nUMR – Claim Appeals  \nPO Box 30546  \nSalt Lake City, UT 84130 – 0546  \nUMC 0033 0820","cbCaiaj18BWL44lP","https://ap.wps.com/l/cbCaiaj18BWL44lP","pdf",148045,"English","# UMR Post-Service Provider Request Form\n## Required Claim Information\n## Submission Procedures and Contact Details","[{\"question\":\"What is the purpose of the UMR Post-Service Provider Request Form?\",\"answer\":\"The form is used by healthcare providers to request a formal review of an adverse benefit determination or a claim denial by UMR.\"},{\"question\":\"What documentation should be included with the request?\",\"answer\":\"Providers should include relevant medical records such as office notes, laboratory results, operative reports, and patient medical history to support the appeal.\"},{\"question\":\"How can a provider submit the completed request form?\",\"answer\":\"The form can be submitted electronically through the UMR portal or by faxing/mailing the completed document along with medical records to the address and fax number provided on the form.\"}]","UMR Post-Service Provider Request Form | PDF"]