Medical Claim Form
What is this form for?
This form is for out-of-network claims ONLY, to ask for payment for eligible health care you have received.
To ensure faster processing of your claim, be sure to do the following:
If you write on the form, use black or blue ink and print clearly and legibly. You can also use your computer to complete
this form and then print it out to mail it to us. Complete all of the applicable ﬁelds on the form. Ask your provider for the
Provider Information, or have them ﬁll that out for you. Be sure to submit a separate form for each claim.
If you have other insurance or Medicare and it is primary to your UnitedHealthcare plan, please include the explanation
of beneﬁts (EOB) from your other insurance or Medicare.
Ask your provider to complete the Provider Information section on the form (below). All of the information in
that section is required to process the claim.
Ask your provider to give you a Superbill or Invoice that includes all of the following
for each date of service:
IMPORTANT: This information must be on the Superbill as it is required to process the claim. Missing information can
result in a delay or non-payment of the claim. Please be sure the information is clear and readable.
• Patient Name
• Diagnosis codes. [Claims with date of service after October 1, 2016 must be ICD10].
• Procedure Codes (CPT, HCPC) - with any applicable modiﬁers.
• Units for each procedure code.
• The billed amount for each procedure code.
• Place of service code.
How to get the maximum beneﬁt:
Use a participating provider to receive the maximum beneﬁt. Durable medical equipment and ongoing services such
as physical therapy are especially cost eﬀective with a UnitedHealthcare provider.
Please review your beneﬁts at myuhc.com. For services that require prior authorization or notiﬁcation, be sure to call
the Member Services number on the back of your health plan ID card.
What happens next:
After we process your claim, we will send you an Explanation of Beneﬁts (EOB). The EOB will explain the charges
applied to your plan deductible and any charges you owe your health care provider. Please keep your EOB on ﬁle for
future reference. You also may review your EOB information online at myuhc.com.
Once you have completed the form, mail it to the address listed on the back of your Health Plan ID Card.
Be sure to attach the Superbill or Invoice and any receipts of your payments.