MHN   Starting June 13, 2021, a new login experience will ask you to update your password the first time you log in.
Your password reset link will be sent to the email on file. Please be sure to update your email address if needed. Log In
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Research and Review Form

*Required field(s)
*Provider Name:
*Federal Tax ID#:
Provider Contact Information:
*Email Address:
Fax:
*Daytime Phone:
(###-###-####)
Member Information:
Patient Name:
Subscriber ID:
DOS(s) in question:
Claims Issue (Please Check One): No Response Received on Claim
Claim Denial Disputed
Incorrect Payment Received
Other (Please give brief description of problem)
Additional Comments: