The UMR predetermination request form, UMF0060, is a one-page fax cover sheet you or your provider submit before a planned procedure so UMR can estimate what your employer-sponsored plan will cover. Download it from UMR’s Form Center at umr.com, or submit the request electronically through the provider portal. Know one thing going in: UMR treats predeterminations as courtesy reviews, not binding coverage guarantees, and the form itself states there is no set turnaround time for a decision.1UMR. Predetermination Request Form
What a Predetermination Actually Gets You
A predetermination is a voluntary review that tells you whether UMR considers a proposed service medically necessary under your plan and roughly what the plan expects to pay. It is not the same as prior authorization. Prior authorization is mandatory for certain services, and skipping it lets the plan deny the claim entirely. UMR’s portal tool lists the two separately, flagging services where “prior authorization is required or pre-determination recommended.”2UMR. Prior Authorization
Because it’s a courtesy review, the written result is an estimate. If your plan terms, network status, or clinical picture change before the procedure, the final claim can land differently. Predeterminations also cannot be reviewed after the service has already been performed, so the request has to go in beforehand.1UMR. Predetermination Request Form Even with those limits, having a written review in hand is far better than guessing on an expensive procedure.
What to Gather Before You Start
The most common reason a request stalls is missing information. Pull everything together first:
- Patient’s full name, date of birth, and Member ID exactly as shown on the front of the insurance card.
- Provider and facility name, phone, fax, mailing address, and TIN or NPIN. These are needed if the request isn’t being set up through the provider portal.1UMR. Predetermination Request Form
- CPT codes for each procedure, with the number of units. For an unlisted CPT code, write the name of the service or procedure it relates to.1UMR. Predetermination Request Form
- Diagnosis codes. The paper form doesn’t have a dedicated field, but UMR’s portal submission tool calls them “highly recommended for precise results,” so include them either way.3UMR. Prior Authorization Requirement Search and Submission Tool
- The planned date of service.
- Recent clinical documentation: office notes, imaging, lab work, or any other records that show why the procedure is needed.
- Pricing information, if the request is for durable medical equipment or a drug.1UMR. Predetermination Request Form
Some procedures have their own supplemental forms in UMR’s Form Center. Check for a procedure-specific form and include it if one exists.
Filling Out the Form
The form is a single-page fax cover sheet. It’s built for a provider’s office to complete, but a member coordinating directly can fill it out too.
Start with the patient block: name, date of birth, Member ID. Then the service block: date of service and CPT codes with unit counts. Fill in provider and facility details if you aren’t using the portal.
Use the Comments section for anything the structured fields don’t cover, such as the name tied to an unlisted CPT code or a short note on clinical rationale. Don’t try to pack a full medical history into that box; the attached clinical records do that work. The form directs you to attach recent office notes and imaging, plus pricing when the request involves DME or drugs.1UMR. Predetermination Request Form
Check the Member ID against the card one more time before sending. A transposed digit means UMR can’t match the request to the right employer plan, and nothing moves until it does.
How to Submit
Provider Portal
The fastest route is the Prior Authorization Requirement Search and Submission Tool inside UMR’s secure provider portal. After signing in at umr.com, the provider uses Member Search to look up the patient, confirms whether a predetermination is recommended, and submits the request electronically through the same tool. Clinical documents upload directly. If UMR’s clinical team later asks for more records, they issue a Case ID and Passcode that lets the provider send additional documents through a separate “Submit documents using Passcode” feature.2UMR. Prior Authorization
Fax
If the provider isn’t on the portal, fax the completed form with all attachments to 877-442-1102.4UMR. UMR Predetermination Request Form The form itself is the cover sheet, so list the total page count (cover sheet plus attachments) and keep the fax confirmation page as proof of submission.
Before sending through either channel, UMR recommends calling the benefit department at the phone number on the back of the member’s insurance card to confirm the procedure’s benefit details.4UMR. UMR Predetermination Request Form
If you faxed the form, there’s no automated tracking. Follow up by calling the number on the insurance card and reference the fax date and the patient’s Member ID.
What Happens After You Submit
UMR’s clinical team reviews the submitted CPT codes and clinical documentation against the medical policies that apply to the member’s plan. There is no published turnaround window. The form itself states that predeterminations have “no time frame for determination” and are not treated as urgent or expedited.1UMR. Predetermination Request Form Simpler requests tend to move faster than complex ones, but UMR doesn’t commit to a standard timeline.
The review ends one of three ways: the service is approved as medically necessary under the plan, the service is denied, or UMR asks for more information before deciding. If more records are requested, send them promptly through the portal using the Case ID and Passcode so the review keeps moving.
Keep in mind that an approved predetermination is still an estimate. The actual claim is adjudicated after the service happens, and payment depends on plan terms in effect that day, the provider’s network status, and the final billing codes. A written approval still makes it much harder for a claim to be denied on medical-necessity grounds if nothing material changed between the review and the procedure.
If the Request Is Denied
A denied predetermination can be appealed. UMR administers employer-sponsored group health plans, which fall under federal ERISA rules giving you at least 180 days from the date of the adverse determination notice to file an appeal. For pre-service determinations, which is the usual posture of a predetermination, the plan must respond within 30 days of receiving the appeal.5eCFR. 29 CFR 2560.503-1 – Claims Procedure
UMR accepts appeals by fax at 877-291-3248 or by mail at:
UMR – Claim Appeals
PO Box 30546
Salt Lake City, UT 84130-05466UMR. UMR Post-Service Appeal Request Form
Include any clinical evidence that wasn’t part of the original submission: a letter of medical necessity from the treating physician, peer-reviewed studies supporting the procedure, or records showing that less invasive alternatives were tried and failed. If you’re appealing for someone else, include UMR’s Designation of Authorized Representative form with the request.