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)

Request Type field is required

Date of submission:

Date of submission field is required

Submitter’s Contact Information:

Name:

Name field is required

Email:

Email field is required

Phone Number:

Phone Number field is required

Patient Name:

Patient Name field is required

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

Patient D.O.B. field is required

UMR ID:

UMR ID field is required

SHO Case Reference ID (if known):

Plan Name:

Plan Name field is required

Plan Type:

Plan Type field is required

Please provide a brief description of the request:

Please provide a brief description of the request field is required

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

Inpatient Outpatient

Is the request for Inpatient or Outpatient services field is required

Inquiry Category (please check one)

Claim Preservice Retro Reconsideration

Inquiry Category field is required

Please attach claims and clinical information for review

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