Ubh Health Claim Inquiry Form PDF Details

When it comes to managing health claims, especially for behavioral health services, the process can sometimes feel daunting for clinicians and hospitals alike. This is where the United Behavioral Health Claim Inquiry/Adjustment Request Form steps in as a vital tool, streamlining the process for healthcare providers contracted with United Behavioral Health (UBH), including those under PacifiCare Behavioral Health. Not designed for use by California providers—who have a different procedure to follow—this form enables healthcare professionals to request adjustments to claims for UBH members efficiently. It's structured to assist through either an initial Claim Inquiry/Adjustment Request or, if necessary, escalate to a Formal Provider Dispute. This initial submission acknowledges the understanding that the request will be processed as an adjustment, with a guidance to allow 30 days for this process. Further, in the event of unresolved issues, providers have the option to submit a Formal Provider Dispute. The form requires detailed member and provider information, alongside the specific reason for the request—ranging from denied claims due to filing errors to incorrect application of contracted rates. It's clear that this form acts as a crucial step towards resolving claims issues, offering a procedural pathway to ensure both providers and members are treated fairly and efficiently.

Form NameUbh Health Claim Inquiry Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesoptum express, ubh provider express, provider express login, optum provider express

Form Preview Example

DATE FORM COMPLETED: _________________________

United Behavioral Health Claim Inquiry/Adjustment Request Form

(Not for use by California providers; see instructions at bottom of page)

Instructions: This form is to be completed by United Behavioral Health contracted clinicians or hospitals to request a claim adjustment for a United Behavioral Health (including PacifiCare Behavioral Health) member.

There are two stages available: 1) Claim Inquiry/Adjustment Request and 2) Formal Provider Dispute* (See attached description)

UBH Contracted Individual Clinician


UBH Contracted Group

First Submission (Claim Inquiry/Adjustment Request) – I understand by checking “First Submission” this request will be handled as a Claim Adjustment. Please allow 30 days to process this request. After 30 days, if you have not received an adjustment, please contact Customer Service by calling the telephone number on the back of the member’s identification card.

Mail Address: For UBH Members - P.O. Box 30757 Salt Lake City UT 84130

For PBH Members - P.O. Box 30602 Salt Lake City UT 84130

(NOTE: This is the first step in resolving a claims issue. It is recommended that you complete the Claim Inquiry/Adjustment Request before you submit a Provider Dispute.)

Subsequent Submission (Formal Provider Dispute) – I understand by checking Subsequent Submission this request will be considered a Provider Dispute, and all pertinent information to support the Dispute is attached.

Mail Address: For UBH Members - P.O. Box 30757 Salt Lake City UT 84130

For PBH Members - P.O. Box 30602 Salt Lake City UT 84130


Enrollee ID: ________________________________________

Enrollee Name: Last_________________________________________ First_______________________________ MI__________

Patient Name: Last__________________________________________ First_______________________________ MI__________

Control / Claim #: ___________________________ D.O.S. __________________________ Billed Amount__________________


Tax Identification Number: ______________________________________ NPI Number: _________________________________

Clinician Name (as listed on PRA / EOB): Last ___________________________First________________________MI__________

and/or Facility/Group Name___________________________________________________________________________________

Contact Person: _________________________________________ Phone Number: _____________________________________


1. Claim previously denied / closed as “Exceeds Filing Time” (attach valid proof of timely filing)

2. Claim previously denied / closed for “Additional Information” (provide description and/or requested documents)

3. Claim previously denied / closed for lack of Authorization/Notification (include notification information)

4. Claim previously denied / closed for “Coordination of Benefits” information (attach primary carrier’s EOB)

5. Claim previously processed but contracted rate applied incorrectly resulting in over/underpayment (explain below)

6. I am resubmitting a corrected claim (explain correction below)


Required Attachments: Copy of Provider Remittance Advice (PRA) and Claim form (with corrections if necessary)

Additional Information: Other required attachments as listed above



This form is to be completed by United Behavioral Health contracted clinicians or hospitals to request a claim adjustment for a United Behavioral Health (including PacifiCare Behavioral Health) member. You may also call the telephone number on the back of the member's identification card for information on how to request claim reviews.

For claim inquiries in California, do not use this form. Instead, please call the telephone number listed on the Explanation of Benefits

(EOB) or the Provider Remittance Advice (PRA) for assistance.

Formal Provider Dispute Process

Your Right to Dispute an Adverse Determination on Your Own Behalf

You or your authorized representative, on your own behalf, have the right to dispute the adverse determination made by United Behavioral Health (UBH). You may initiate this dispute in writing by completing the “UBH Claim Inquiry/Adjustment Request Form” and checking the “Subsequent Submission” checkbox. This will be considered a Formal Provider Dispute.

The First Level Provider Dispute Process

The Provider Dispute process can be initiated for post service requests only.

You must request a Provider Dispute review within one hundred eighty (180) calendar days of the date you received your adverse determination letter from UBH. Disputes received outside of this timeframe will not be processed.

UBH will notify you or your authorized representative of the dispute resolution (including any additional levels of the dispute process, as applicable) in writing within thirty (30) calendar days of the receipt of your request.

If UBH does not receive the minimum necessary information to process your dispute as described above, UBH will send written notice to you within thirty (30) calendar days of our receipt of your request that contains 1) a description of the information needed from you to process your dispute, and 2) a statement that failure to provide the requested information within thirty (30) calendar days of receipt will result in the closure of the request with no further review.

For Colorado Providers, UBH will provide you the opportunity to present your rationale for your dispute in person, or via an alternative method, such as a teleconference.

How to Edit Ubh Health Claim Inquiry Form Online for Free

It is easy to fill out the provider express claims. Our PDF editor was made to be allow you to prepare any PDF easily. These are the basic steps to go through:

Step 1: Hit the orange button "Get Form Here" on the page.

Step 2: The document editing page is presently available. You can add text or manage current information.

Type in the requested information in each area to complete the PDF provider express claims

part 1 to filling in provider express

Fill in the Enrollee ID, ENROLLEEMEMBER INFORMATION, Enrollee Name Last First MI, Patient Name Last First MI, Control Claim DOS Billed Amount, Tax Identification Number NPI, CLINICIANHOSPITAL INFORMATION, Clinician Name as listed on PRA, andor FacilityGroup Name, Contact Person Phone Number, REASON FOR REQUEST, Claim previously denied closed, and Comments section with the particulars asked by the platform.

Completing provider express step 2

Step 3: When you are done, select the "Done" button to upload the PDF file.

Step 4: It's going to be simpler to keep copies of the document. You can rest assured that we will not publish or see your details.

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