UnitedHealthcare Community Plan Medicaid Pre-Service Appeals & Grievances

You may be required to provide authorization and/or patient consent when completing this form. If authorization and/or patient consent is required, and not provided, you will be notified, and this may result in a delay in the processing of this submission.

UnitedHealthcare Community Plan Medicaid AOR Form

To complete this submission, you may be required to provider some or all the following information:

• Member ID
• Member date of birth
• Member Group/Contract #
• Authorization/Alert Number if pre-service
• Tax Identification Number
• National Provider Identification (NPI)