REPRICED CLAIM REJECTION

UNION PACIFIC HEALTH SYSTEMS
P.O. BOX 4136, SALT LAKE CITY, UTAH 84110 - 4136

PLAN:_______________________________________________________________________

WHFA GROUP # __________________________DATE:_______________________________

PLAN ADMINISTRATOR:________________________________________________________

ADDRESS:___________________________________________________________________

____________________________________________________________________________

DEAR WHFA MEMBER:

UPHS IS UNABLE TO REPRICE THE ATTACHED FOR THE REASON(S) STATED BELOW.
YOU MAY SUPPLY THE MISSING INFORMATION AND RESUBMIT.

1.) INCOMPLETE PLAN INFORMATION

________WHFA GROUP NUMBER
________PLAN NAME
________COMPLETED REPRICING REQUEST

2.) INCOMPLETE CLAIM FORM

________COMPLETED CLAIM FORM OR ITEMIZED STATEMENT REQUIRED. PAID
RECEIPTS AND / OR BALANCE DUE STATEMENTS CANNOT BE PROCESSED.
________MISSING DATE(S) OF SERVICE
________MISSING ICD DIAGNOSIS CODE(S) OR CPT CODE(S)
________MISSING TYPE OF SERVICE OR PLACE OF SERVICE
________INCORRECT MODIFIERS
________PROVIDER NAME AND / OR ADDRESS

3.) INCOMPLETE MEMBER INFORMATION:_______________________________________

___________________________________________________________________________

4.) OTHER:_________________________________________________________________

___________________________________________________________________________

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT:
JUDY RAUSCHMEIER ( 801 ) 595-4364
DEBORAH FORBUSH ( 801 ) 595-4336