Student Claim Form North Carolina (Page 2 of 2) in pdf

Student Claim Form North Carolina Page 2

HOW TO FILE A CLAIM FORM

THIS CLAIM FORM MUST BE SENT WITHIN 90 DAYS OF THE DATE YOU FIRST RECEIVED MEDICAL CARE.

IF YOU DID NOT SIGN THE REVERSE SIDE TO PAY BENEFITS TO PROVIDER, YOU MUST INCLUDE ORIGINAL

RECEIPTS FOR EACH PAID BILL. KEEP COPIES OF ALL CLAIM FORMS, BILLS AND CORRESPONDENCE FOR

YOUR OWN RECORDS UNTIL YOUR CLAIM HAS BEEN PROCESSED.

PLEASE FOLLOW THESE INSTRUCTIONS:

1. All lines must be completely filled out and be sure to sign the Medical Authorization.

2. Send ORIGINAL ITEMIZED BILLS with diagnosis and the corresponding EXPLANATION OF BENEFITS

NOTICE FROM YOUR PRIMARY CARRIER. (Keep copies for your records) BALANCE FORWARD

STATEMENTS ARE NOT SUFFICIENT.

3. Mail completed form to: UnitedHealthcare StudentResources, P. O. Box 809027, Dallas, TX 75380-9027.

4. Attach itemized bill to completed claim form. An itemized bill must include:

a. School District name

b. Patient’s name

c. Patient’s complete address

d. Diagnosis

e. Date of service(s)

Description of treatment (i.e. type of x-ray, office visit, lab test, etc.). Including CPT (procedure) codes

g. Doctor’s/Hospital name, address and telephone number

5. Please do not send bills without a completed claim form. The bills will not be processed with partial information.

NOTE: The Policy Number is 08-1775.

FRAUDULENT CLAIM DISCLOSURE

correct, misleading or undisclosed information regarding other insurance coverage can result in duplicate payments

g a substantial overpayment. Any person who, knowingly and with intent to defraud, files a statement of claim

ning materially false information or conceals information concerning any material fact, commits fraudulent insurance

hich is a federal offense. Any attempt to collect full primary benefits in excess of the total covered expenses under

more group insurance plans is considered mail fraud and will fall under federal jurisdiction.

Student Claim Form North Carolina Page 2