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 or fax 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 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
• 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.