UnitedHealthcare Request for Other Insurance Coverage
This form is used to provide UnitedHealthcare with details about other insurance coverage you may have. Coordinating benefits with all insurers ensures you receive the maximum benefits available. Please complete and return via mail or fax as directed.
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How do I fill this out?
To complete this form, gather all relevant insurance information and follow the instructions provided. Fill out each section accurately to ensure proper processing. Sign and return the form as directed.
How to fill out the UnitedHealthcare Request for Other Insurance Coverage?
1
Gather information about other insurance or Medicare coverage.
2
Complete the sections relevant to your other insurance or Medicare coverage.
3
Fill out required details such as policy numbers, coverage dates, and personal information.
4
Provide information about dependents if applicable.
5
Sign the form and return it via mail or fax.
Who needs the UnitedHealthcare Request for Other Insurance Coverage?
1
Policyholders with other insurance coverage need this form to coordinate benefits.
2
Individuals with Medicare coverage need this form to report their Medicare details.
3
Parents of dependents with other insurance need this form to provide coverage information.
4
Divorced or separated parents with dependent children need this form to report coverage responsibilities.
5
Members seeking maximum benefits from multiple insurers need this form to coordinate coverage.
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On PrintFriendly, you can easily edit the PDF form to fill in your insurance details. Use our PDF editor to make necessary changes and inputs. Save and download the edited file once complete.
1
Upload the PDF form to PrintFriendly.
2
Use the PDF editor to fill in your insurance information.
3
Review the details to ensure everything is accurate.
4
Save the edited form.
5
Download the completed PDF for submission.
What are the instructions for submitting this form?
Submit the completed form via mail to the address on your Member ID card or fax it to 801-567-5498. Ensure all required fields are accurately filled out and signed before submission. Confirm the receipt of your form by contacting UnitedHealthcare.
What are the important dates for this form in 2024 and 2025?
This form should be submitted as soon as possible whenever there is a change in your other insurance or Medicare coverage to ensure continuous coverage and benefits.
What is the purpose of this form?
The purpose of this form is to inform UnitedHealthcare about any additional insurance or Medicare coverage you may have. By providing this information, UnitedHealthcare can coordinate benefits with all involved insurers to ensure you receive the maximum available benefits. This form is essential for accurate benefit processing and timely claims management.
Tell me about this form and its components and fields line-by-line.
- 1. Member Name: Enter the full name of the member holding the UnitedHealthcare policy.
- 2. Date of Birth: Enter the date of birth of the member.
- 3. Policy Number: Enter the UnitedHealthcare policy number.
- 4. Member ID Number: Enter the Member ID number as seen on the Member ID card.
- 5. Claim Number (if applicable): Provide the claim number if it is applicable to this form submission.
- 6. Patient Name: Enter the full name of the patient if different from the member.
- 7. Name of Insured: Enter the full name of the person who holds the other insurance policy.
- 8. Phone Number: Provide a contact phone number for the insured.
- 9. Relationship of insured to Patient: Indicate the relationship of the insured to the patient (e.g., self, spouse, parent).
- 10. Other Insurance Carrier: Enter the details of the other insurance carrier including the employer name, carrier name, policy number, coverage dates, and group number.
- 11. Insurance Carrier phone number: Provide a contact phone number for the other insurance carrier.
- 12. Group Number: Enter the group number associated with the other insurance policy.
- 13. Dependent Information: If applicable, provide names and relationships of dependents who are covered by the other insurance policy.
- 14. Court Decree Information: If applicable, indicate if a court decree assigns primary responsibility for health care coverage and provide related information.
- 15. Medicare Information: Provide details on Medicare coverage including the individual covered, Medicare ID, retirement date, and effective dates for Medicare parts.
- 16. Signature: The insured or patient must sign and print their name, and provide the date of signature.
What happens if I fail to submit this form?
Failure to submit this form may result in delayed or denied claims and reduced benefit coordination. It is crucial to submit accurate information promptly.
- Delayed Claims: Claims processing may be delayed due to insufficient coordination of benefits.
- Denied Claims: Claims might be denied if necessary insurance information is not provided.
- Reduced Benefits: Inaccurate or missing information can lead to reduced benefits from your insurance policies.
How do I know when to use this form?
- 1. New Insurance Coverage: When you obtain new insurance coverage in addition to UnitedHealthcare.
- 2. Medicare Enrollment: When you enroll in Medicare and need to report this coverage.
- 3. Dependent Coverage: When your dependent has additional insurance coverage.
- 4. Change in Coverage: Anytime there is a change in your existing insurance or Medicare coverage.
- 5. Court-Decreed Responsibility: When a court assigns health care coverage responsibility to you.
Frequently Asked Questions
How do I fill out the UnitedHealthcare Other Insurance Coverage form?
Gather your other insurance details and fill out the relevant sections of the form. Ensure all information is complete and accurate.
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What information do I need to complete this form?
You will need details about your other insurance or Medicare coverage, including policy numbers and coverage dates.
Who needs to fill out this form?
Policyholders with other insurance or Medicare coverage and parents of dependents with additional coverage need to fill out this form.
Where do I submit the completed form?
Submit the completed form via mail to the address on your Member ID card or fax it to 801-567-5498.
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