Fillable Medical Claim Form What is this form for? (United Healthcare)

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Medical Claim Form What is this form for? (United Healthcare)

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The Medical Claim Form What is this form for? (United Healthcare) form is 2 pages long and contains:

  • 1 signature
  • 1 check-box
  • 73 other fields

Country of origin: US
File type: PDF

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Oxford
|
Medical
|
New York
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 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 Oxford medical 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
• Date(s) of Service
• 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 an Oxford participating provider.
Please review your benefits at myuhc.com®. For services that require precertification (sometimes referred to as preauthorization) or
notification, be sure to call the Member Services number on 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.
B2C 8/19 © 2019 Oxford Health Plans LLC. M57295-A 12092 R1
CPT® is a registered trademark of the American Medical Association.
Oxford insurance coverage provided by Oxford Health Insurance Inc.
Home Address:
Home Address:
Provider Address:
Name (Last, First, MI):
Address Where Services Were Rendered:
Member ID (from Health Plan ID card, can be up to 11 digits): Group Number (can be 6 or 7 digits):
Phone #:
( )
Date of Birth:
New Address?:
Yes No
City:
City:
City:
State:
State:
ZIP Code:
ZIP Code:
State: ZIP Code:
Gender: M F
Relationship to Subscriber /
Policyholder:
Subscriber/Policyholder
Spouse/Partner
Child
Other Dependent
–
Phone Number:
( )
–
Phone #:
( )
–
Employee Name (Last, First, MI):
Provider (or Rendering Provider) Name:
NPI Number:
Date of Birth:
Type of Accident:
Work Auto Other
Date of Accident:
How did the accident happen?
Provider Tax Identification Number:
Group/Facility Name:
New Address?: Yes No
Patient Information.
Policyholder Information. (Complete this section only if it is different than the patient information.)
Provider Information. This information is required to process the claim. Ask your provider for this information or have them fill it out for you.
Accident Information. (If applicable)
Name of Other Insurance Carrier:
Effective date of Other Insurance:
Name of Person Carrying Other Insurance (Last, First, MI): Date of Birth (of person carrying other insurance):
Is the patient covered by another insurance plan?
Yes No (If yes, please complete the following information.)
Policy Number:
Cancellation date of Other Insurance (if applicable):
Employer Name:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Please check this box if you want Oxford to pay benefits directly to the doctor/provider.
Other Insurance.
Assignment of Benefits.
Did you attach an EOB from Medicare or
your other insurance?:
Yes No
Signature:
Date:
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Medical Claim Form What is this form for (United Healthcare)

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Completed 1 January 2021

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