EDI Transaction Support Form

This report should be used for EDI related issues only. Report suspected problems with electronic submissions through a clearing house. Use this for issues including: Provider/Billing or Clearinghouse receiving a rejection message, experiencing problems with the 837 or checking claim status and claims not on a file.

Print Form

Contact Information

Contact Name (UHG Associate Contact)

Person reporting issue on behalf of the user.

Role of Contact

Phone

Tax Identification Number

Billing Provider NPI

Issue Details

Select a Product

Select a Function

Provide a detailed explanation of the issue

Maximum: 200 characters.

Include the rejection message if available.

Additional Information

If the issue is impacting more than one member, provide only one member as an example.

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