Noblesville Schools Medical Plan 75 Section 5: How to File a Claim Section 5: How to File a Claim Claims Procedures You can obtain a claim form by contacting the Claims Administrator at www.myuhc.com or the telephone number on your ID card. If you do not have a claim form, attach the bill from your provider to a brief letter of explanation. Verify that your provider's bill contains the Required Information listed below. If any Required Information is missing from the bill, you can include it in your letter. How Are Covered Health Care Services from Network Providers Paid? The Claims Administrator processes payment to Network providers directly for your Covered Health Care Services. If a Network provider bills you for any Covered Health Care Service, contact the Claims Administrator. However, you are required to meet any applicable deductible and to pay any required Copayments and Coinsurance to a Network provider. How Are Covered Health Care Services from an Out-of-Network Provider Paid? When you receive Covered Health Care Services from an out-of-Network provider, you are responsible for requesting payment from the Claims Administrator. You must file the claim in a format that contains all of the information the Claims Administrator requires, as described below. You should submit a request for payment of Benefits within 90 days after the date of service. If you don't provide this information to the Claims Administrator within one year of the date of service, Benefits for that health care service will be denied or reduced, in the Claims Administrator's discretion. This time limit does not apply if you are legally incapacitated. If your claim relates to an Inpatient Stay, the date of service is the date your Inpatient Stay ends. Required Information When you request payment of Benefits from the Claims Administrator, you must provide the Claims Administrator with all of the following information: • The Participant's name and address. • The patient's name and age. • The number stated on your ID card. • The name and address of the provider of the service(s). • The name and address of any ordering Physician. • A diagnosis from the Physician. • An itemized bill from your provider that includes the Current Procedural Terminology (CPT) codes or a description of each charge. • The date the Injury or Sickness began. • A statement indicating either that you are, or you are not, enrolled for coverage under any other health plan or program. If you are enrolled for other coverage you must include the name of the other carrier(s). The above information should be filed with the Claims Administrator at the address on your ID card.