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

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Medical Claim Form What is this form for? (GEHA)

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Country of origin: US
File type: PDF

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What is this form for?
Use this Medical Claim Form to ask for payment for eligible care you've already received.
Did you know?
You receive a higher benefit if you use a UnitedHealthcare provider. This can
be especially cost effective when receiving ongoing services like physical
therapy or when purchasing durable medical equipment.
Things to remember
• Complete this form on your computer before printing it. You can also complete it
by
hand.
• Make a copy of this claim form, claim details and receipt(s) to keep for your records.
• Send the claim as soon as you can and as
close to the date of service as possible.
• Be sure your member ID and the provider’s or facility's details are clear and
complete on the claim. This will help you receive faster payment.
• Send a detailed claim of the services from your provider, not just a receipt of your
payment. Details like service codes and diagnosis codes are needed to process
your claims quickly and correctly.
If you have not paid your out-of-network
bill in full, mail your claim form to:
UnitedHealthcare Shared Services
P.O. Box 30783
Salt Lake City, UT 84130-0783
What happens next
After processing your claim, you’ll receive an Explanation of Benefits (EOB). The EOB explains
the charges applied to your deductible (the amount you pay for covered services before your plan
begins to pay) and any charges you may owe the provider. Please keep your EOB on file in case
you need it in the future.
Medical Claim Form
GF-FRM-0118-001
If you have already paid your out-of-network
bill in full, mail your claim form to:
GEHA
P.O. Box 21542
Eagan, MN 55121
Member ID (from Health Plan ID card): Group Number (from Health Plan ID card):
Name (Last, First, MI):
Patient Information
Date of birth:
Home address:
City:
Phone #:
(
)
State:
–
ZIP Code:
Gender:
M
F
New address?
Yes
No
Relationship to Subscriber /
Policyholder:
Subscriber/Policyholder
Spouse/Partner
Child
Other dependent
Subscriber/Policyholder Information
(Complete this section only if it is different than the patient information.)
Employee name (Last, First, MI):
Home address:
Phone #:
( )
–
Date of birth:
City:
State:
ZIP Code:
New Address?
Yes
No
Provider name:
Provider Information
Provider Tax Identification #:
Accident Information
Date of accident:
Provider address:
City:
State:
ZIP Code:
Type of accident:
Work Auto
Other
How did the accident happen?
Other Insurance
Is the patient covered by another insurance plan?
Yes
No (
If yes, please complete the following information.)
Name of person carrying other insurance (Last, First, MI): Date of Birth:
Name of other insurance carrier:
Policy number: Employer name:
G E H A
7 8
-
GF-FRM-0118-001
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Medical Claim Form What is this form for (GEHA)

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Completed 21 May 2021

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