REPRICED CLAIM RESPONSE

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

PLAN:_______________________________________________________________________

WHFA GROUP # _____________________________DATE:____________________________

PLAN ADMINISTRATOR ( SELF, TPA, ETC. ):_______________________________________

ATTENTION:_________________________________________________________________

ADDRESS:__________________________________________________________________

____________________________________________________________________________

YOU REQUESTED REPRICING OF THE FOLLOWING CLAIM:

PATIENT NAME:_____________________________________________________________

MEMBER NAME:_____________________________________________________________

MEMBER HI # :_______________________________________________________________

ADMISSION OR SERVICE DATE(S):______________________________________________

HOSPITAL OR PROVIDER:_____________________________________________________

ADDRESS:__________________________________________________________________

____________________________________________________________________________

ORIGINAL BILL AMOUNT: $_____________________________________________________

UPHS DISCOUNT AMOUNT: $___________________________________________________

PAY THE FOLLOWING AMOUNT: $_______________________________________________

THE FOLLOWING STATEMENT SHOULD BE INCLUDED IN YOUR EXPLANATION OF
BENEFITS, OR APPEAR WITH YOUR CHECK ENDORSEMENT:_____ UPHS AGREEMENT
RATE APPLIED.