Submitting medical or Rx benefit claims
If you have other healthcare coverage, see Participating in Healthcare Benefits for information on how that coverage may impact your claims.
A claim for benefits is a specific request for a plan benefit that is submitted in accordance with the plan's procedures for filing claims. There are three types of claims for medical benefits, each of which is subject to different rules.
- An urgent care claim is a type of pre-service claim that, if the regular time periods for handling pre-service claims were followed:
- Could seriously jeopardize your life or health or your ability to regain maximum function, or
- Would, in the opinion of a physician with knowledge of your medical condition, subject you to severe pain that could not be adequately managed without the care or treatment that is subject to the claim.
- A pre-service claim is a claim for a benefit that requires prior approval or notification under the terms of the plan, such as inpatient admission notification.
- A post-service claim is a claim for a benefit that does not require prior approval under the terms of the plan. A post-service claim involves a claim for payment or reimbursement for medical care, medications or supplies that have already been received.
A pre-service claim is considered submitted when UnitedHealthcare receives a request for prior approval. See the "Notification Requirement" section of Medical Benefits or "Prior Authorization" in the Prescription Drug Benefits section of this Benefits Summary for the procedures for notification or approval.
If you filed a pre-service claim improperly, UnitedHealthcare will notify you of the improper filing and how to correct it within five days after the pre-service claim was received. If additional information is needed to process the pre-service claim, UnitedHealthcare will notify you of the information needed within 15 days after the claim was received, and may request a one-time extension, not longer than 15 days, and pend your claim until all information is received. Once notified of the extension, you then have 45 days to provide this information. If all of the needed information is received within the 45-day time frame, UnitedHealthcare will notify you of the determination within 15 days after the information is received. If you don't provide the needed information within the 45-day period, your claim will be denied. An adverse benefit determination notice will explain the reason for the adverse benefit determination, refer to the part of the plan on which the adverse benefit determination is based and provide the claim appeal procedures.
In-network providers will generally submit their claims for payment directly to UnitedHealthcare. If you obtain services from an out-of-network provider, or if you are enrolled in the Out-of-Area plan, you must pay for the services and submit a claim for reimbursement.
A claim is considered submitted when UnitedHealthcare receives it.