UMR Inquiry Form

SHO UM will respond within 3 business days to urgent inquiries and
14 business days to routine inquiries.

For UMR use only

Request Type:

Routine (14 business days) Urgent (3 business days)

Date of submission:

Submitter’s Contact Information:

Name:

Email:

Phone Number:

Patient Name:

Patient D.O.B. (format 00/00/00)

UMR ID:

SHO Case Reference ID (if known):

Plan Name:

Plan Type:

Please provide a brief description of the request:

Is the request for Inpatient or Outpatient services (please check one)

Inpatient Outpatient

Inquiry Category (please check one)

Claim Preservice Retro Reconsideration

Please attach claims and clinical information for review

Need additional assitance? Please send a message to: nvshomailbox@ds.uhc.com