United Healthcare (Oxford) Eligibility Verification Form (Page 3 of 3) in pdf

Summary of Instructions for Responding to Eligibility Verification Audit

Read your cover letter in its entirety.

Complete, sign and submit the Employer Information Form.

Submit the most recent copy of your state Quarterly Wage and Tax Report that lists all of your active

employees.

If there are employees enrolled in the plan who are not listed on the Quarterly Wage and Tax Report, please

submit the following:



New hires: appropriate tax documents include a payroll report with the new hire(s) listed.



Owners: appropriate tax documents include Schedule K-1 or Schedule C.

If the owner(s) is not identified on the state Quarterly Wage and Tax Report or if you do not file a Quarterly

Wage and Tax Report, you must include the owner(s) tax documentation in your response. All owners must be

identified and waiver reasons given for those not enrolled in the policy. If there is more than one owner you must

include all K-1s accounting for 100 percent of all ownership.

Directly on your state Quarterly Wage and Tax Report, next to each name, you must indicate the status of

each employee using the codes provided on the Employer Information Form. If any employee is not covered by

the plan, you must indicate why the employee is not enrolled using the status codes provided on the Employer

Information Form. Make sure that all employees have been accounted for.

Send all required information, including the Employer Information Form and supporting tax documents, by

mail to UnitedHealthcare Risk Management MN012-N123, 5901 Lincoln Drive, Edina, MN 55436-1611; by fax

to 1-877-232-7902; or by e-mail to . We must receive the appropriate and

complete documentation from you by your renewal date or your group’s coverage will not be renewed.

Frequently Asked Questions

1. I have never before received a request for this type of information. What is this for?

We are verifying that eligibility guidelines and requirements are being met as defined in your group policy.

2. What are the guidelines I need to meet?

Please refer to your group policy or contact your Agent for more information. The Risk Management

Department regrets that we cannot provide you with a copy of your group policy.

3. I have a small group [or] I am the owner and have no employees. Do I still need to fill this out as it

does not apply to me?

Yes. If you are a small group business, this does apply to you and you are required to respond.

4. What if I have received an earlier request for this information and I have already responded?

It can take up to five business days to process your information once we receive it. Our automated mailing

system may still have shown that your group had not responded or was in an incomplete status. After your

information has been processed, we will send you a decision letter indicating the results of the audit. We will

also notify your broker, by e-mail.

5. What if I am not comfortable sharing the wages and Social Security numbers of my employees?

In order to prove full time employment based on federal/state wage and hour laws, we must be able to

document earnings. If you prefer, you may black out part of the Social Security number (SSN) but leave at

least the last four digits visible. Remember, UnitedHealthcare is legally obligated to protect the privacy of

your information. The SSN will only be used to validate eligibility.

6. Why did I receive a notice of non-renewal, when I have already received my renewal packet?

The Eligibility Verification Audit is separate from your regular renewal process. The audit must be processed

and approved in order to prevent cancellation of your policy. If we cannot confirm your eligibility

requirements, the renewal information that you received will become invalid.

7. Can I fax or e-mail my response and supporting documentation to you?

Yes. Our fax number is 1-877-232-7902 and our e-mail address is . Please

make sure your group number is referenced on all faxes and e-mails.

United Healthcare (Oxford) Eligibility Verification Form Page 3

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