EDI Transaction Support Form

This form should be used to report EDI related issues only.

EDI Transaction Support Form

Use this form to report suspected problems with electronic submissions through a clearinghouse.

Examples of when to use this form:

Provider/Billing Service or Clearinghouse is receiving a rejection message.

Provider/Billing Service or Clearinghouse is experiencing formatting problems with the 837.

Provider/Billing Service or Clearinghouse checking claim status and claim is not on file.

= Required field = Optional field

1. Contact Information

Note:UHG Associate Contact Information(Person Reporting issue on behalf of the user).
Contact Name:	Phone #:	E-mail Address:
Tax ID:	Billing Provider NPI:	Form completed by:	Provider UnitedHealthcare Employee

2. Please select the Product that this issue is related to:

Select a Product:

3. Please select the function that the issue is related to:

Select a Function:

4. Please provide a detailed explanation of the issue including the rejection message if available:

5. Please complete the following information:

Member Name:	Date of Service:	Date EDI Transaction was Submitted:
Member Id:	Billed Amount:	Claim Number:
Referral/Notification Number:	Check/Payment Number:	Payer ID:
Rendering Provider:	Rendering Provider NPI:	Clearinghouse:
Payer Trace Number:
Note: If issue is impacting more than one member, only one member example should be provided.