Form Gf-Frm-0416-001 - Medical Claim Form

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Medical Claim Form
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.
•
Mail your form with the claim details and receipt(s) to:
EDI Payer ID 39026
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.
GF-FRM-0416-001

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