Medical and Rx Benefits
In-Network Providers
UnitedHealthcare (also known as United HealthCare Services, Inc.) and its affiliates is the claim administrator for medical and prescription drug benefits and pays in-network providers directly for your covered medications and health services. If an in-network provider bills you for any covered health service, contact UnitedHealthcare.
However, you are responsible for paying copayments, your remaining deductible and your coinsurance share to an in-network provider at the time of service or when you receive a bill from the provider.
Out-of-Network Providers
When you receive covered health services from an out-of-network provider, you are responsible for filing a claim in order to obtain reimbursement for the cost of these services. You must file the claim in a format that contains all of the information required, as described in "Required Information."
  • If you are asked to pay the full cost of a prescription when you fill it at a retail or mail-order pharmacy, and you believe that the plan should have paid for it, you may submit a claim for reimbursement following the procedures for filing a post-service claim (see "Submitting Medical or Rx Benefit Claims"). If you pay a copayment and believe that the amount of the copayment was incorrect, you also may submit a claim for reimbursement, again following the procedures outlined for filing a post-service claim.
  • If a retail or mail order pharmacy fails to fill a prescription that you have presented because they believe it is not covered under the plan, you may contact UnitedHealthcare to determine if it is a covered health service. In such a case, you can submit a claim for coverage following the procedures described for filing a pre-service claim (see "Submitting Medical or Rx Benefit Claims").
You must submit a request for payment of benefits within one year of the date of service. If you don't provide this information to UnitedHealthcare within one year of the date of service, benefits for that health service or medication will be denied or reduced at UnitedHealthcare's discretion. This time limit does not apply if you are legally incapacitated.
An individual is considered "legally incapacitated" for plan purposes if they are determined by a court of law to be lacking the capacity to make or communicate responsible personal decisions. A person may also be considered "legally incapacitated" if they exhibit an inability to meet their own personal needs for medical care, nutrition, clothing, shelter or safety. In such a case, a general guardian will be appointed.
If your claim relates to an inpatient hospital stay, the date of service is the date your inpatient stay ends.
If you provide written authorization to allow direct payment to a provider; all or a portion of any eligible expenses due to a provider may be paid directly to the provider instead of being paid to you. UnitedHealthcare will not reimburse third parties who have purchased or been assigned benefits by physicians or other providers.