Claims Center

 

File a Medical Claim

Submit a Claim by Mail

Submit a Claim Electronically

It’s easy! Just download the claim form below. Fill out the first page with: Your personal information Dates of injury or sickness The cause of the injury or date of first symptoms for a sickness Sign and date Attach all receipts. Please be sure to fill out the entire page. Leaving items blank can cause a delay in your claim processing. When sending claim information: Clip, do not staple, all bills to the completed form. Make sure all bills or itemized receipts indicate: A diagnosis code Procedure code Date of service Cost The provider’s tax ID number. Download Medical Claim Form

Your Doctor can also submit a claim electronically, using Emedeon (formerly WebMD). This gives a faster turn-around time than submitting a claim by mail. Check with your doctor to see if they are a participant. If they are, show them your ID Card. The Emedeon information is printed on the back of every ID Card.

File a Prescription Claim

To submit a claim for reimbursement for a prescription that you paid for out of pocket, please print a copy of the Generic Reimbursement Claim Form

Prescription Claim Information Check List

Information and Documents	Directions
Generic Reimbursement Claim Form Date prescription filled Name and address of pharmacy Doctor name or ID number NDC number (drug number) Name of drug and strength Quantity and days’ supply Prescription number (Rx number) DAW (Dispense As Written) Amount paid	Clip, do not staple, all bills to the completed form. Make sure all bills or itemized receipts indicate: A diagnosis code Procedure code Date of service Cost The provider’s tax ID number.

This information can usually be found on the receipt which is stapled on the outside of the packaging or in some cases located inside. Contact your pharmacist for more information.

Download Prescription Claim Form

File an Appeal

To file an appeal, please include the following information:

1. A letter requesting an appeal to your claim(s), including your:
   • Name
   • Address
   • Phone number
   • UnitedHealthcare Student ID number
   • Date of service for your injury/sickness
   • Claim number(s) (located on the top of your Explanation of Benefits)
   • Email address
2. A copy of your Explanation of Benefits for the claim(s) in question.
3. Medical Records including all test results from all providers visited for the specific injury/sickness that you are appealing.

Once we receive the documentation, your appeal will be reviewed and a written response will be mailed to you. The response will include what the findings were, if the appeal was approved or denied, and the reason for the final decision.

Check Claim Status

If you are a student and would like to check on the status of a claim that you or a provider submitted, you will need to set up a MyAccount if you have not done so already.

Please visit our My Account Center to log in to an existing account or to create a new one.