Medical Mutual - Health Plans for Life

How do I inquire about or appeal a claim?

The PAR Form is used for all provider inquiries and appeals related to reimbursement. Providers may request corrective adjustments to any previous payment using this form. Medical Mutual will review the requests and make adjustments within 12 months from the date the initial claim was processed.

How to submit the PAR Form:

  • Log in to the Provider Portal and select the claim you need to inquire about in the Claims & Eligibility feature. Then, click the “Submit Inquiry” button to complete the necessary information and attach the appropriate files.
  • Fill in the required information below and attach any related medical records.

Note: Please use one form per patient or inquiry. Any fields with incomplete information may delay or cause your request to be returned unprocessed.

Questions or Postal Mailings? Please reference the PAR Form Instructions to determine the supporting documentation required for each type of request or what to do when a claim is returned unprocessed.

Fields marked with * are required.

Provider Action Request (PAR) Form

Provider Information

Requester/Contact Name:*

Provider E-mail Address:*

Confirm E-mail Address:*

Telephone Number:*

Nine Digit Tax Number:*

NPI Number:*

Provider Name:*





Zip Code:*

Patient Information

Identification Number:*

Patient Name:*

Claim Number:*

Service Date(s) Questioned:*

Type of Request


COB – Primary Carrier payment info and Medicare Primary EOMB info must be submitted electronically.
Corrected/Replacement Claim/Late Charges – Must be electronically submitted using TOB XX5 or XX7.

Reason for Inquiry:

Attach Documentation
(if applicable)

Attachment File Size Must be less than 10MB

I would like to receive a confirmation email from Medical Mutual that my form was submitted.

Contact Information

If you have any questions regarding contracting, provider inquiry or other administrative policies and procedures Contact Us at the appropriate location.

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