Page 84 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Section 5: How to File a Claim

Claims Procedures

You can obtain a claim form by contacting the Claims Administrator at www.myuhc.com or the telephone
number on your ID card. If you do not have a claim form, attach the bill from your provider to a brief letter
of explanation. Verify that your provider's bill contains the Required Information listed below. If any
Required Information is missing from the bill, you can include it in your letter.

How Are Covered Health Care Services from an Out-of-Network
Provider Paid?

When you receive Covered Health Care Services from an out-of-Network provider, you are responsible
for requesting payment from the Claims Administrator. You must file the claim in a format that contains all
of the information the Claims Administrator requires, as described below.
You should submit a request for payment of Benefits within 90 days after the date of service. If you don't
provide this information to the Claims Administrator within one year of the date of service, Benefits for that
health care service will be denied or reduced, as determined by the Claims Administrator. This time limit
does not apply if you are legally incapacitated. If your claim relates to an Inpatient Stay, the date of
service is the date your Inpatient Stay ends.

Required Information
When you request payment of Benefits from the Claims Administrator, you must provide the Claims
Administrator with all of the following information:
• The Participant's name and address.

• The patient's name and age.
• The number stated on your ID card.

• The name and address of the provider of the service(s).
• The name and address of any ordering Physician.

• A diagnosis from the Physician.
• An itemized bill from your provider that includes the Current Procedural Terminology (CPT) codes
or a description of each charge.
• The date the Injury or Sickness began.

• A statement indicating either that you are, or you are not, enrolled for coverage under any other
health plan or program. If you are enrolled for other coverage you must include the name of the
other carrier(s).
The above information should be filed with the Claims Administrator at the address on your ID card.

Payment of Benefits
If you provide written authorization to allow this, all or a portion of any Allowed Amounts due to a provider
may be paid directly to the provider instead of being paid to the Participant. The Plan will not reimburse
third parties that have purchased or been assigned benefits by Physicians or other providers.

81 Section 5: How to File a Claim