Most of the time, the claims process runs smoothly. Usually, the process begins with claim(s) being submitted by the medical providers either by mail or electronically directly to the insurance company for healthcare services rendered. The claim(s) are received and inventoried by the plan administration office and then routed to the appropriate staff member. The claim(s) are then processed by a claims examiner within 60 days (usually less) of receipt. The claim is completed, at which point you and the medical provider should receive an explanation of benefits (EOB) and the provider should also receive any insurance company payment due to them in accordance with the policy. The student will then be billed by the provider directly for the amount that is determined to be the patient's responsibility. That is how the claims process is suppose to work but, occasionally this process does not work as smoothly as it should.
This resource is provided to give you information about claims issues that can arise and what you should do to address them.
1. What should I do if I haven't received an explanation of benefits from UHCSR within 60 days?
Login to MyAccount, from the UnitedHealthcare StudentResources (UHCSR) home page, to determine if the insurance company has received the claim from the medical provider. If you haven't already done so, you should create an online account now so that you can review your claims status regularly. If you find the completed claim then you should verify that UHCSR has your correct mailing address under My Personal Information and update if necessary. If you find the claim is being processed, please be patient as you should receive an EOB when the claim is completed. If you do not see the claim listed as being processed or completed, you should contact the provider to verify your insurance information including the claims mailing address and your insurance ID number and inquire as to when the claim was submitted. You can also call Customer Service at (800) 767-0700 Monday through Friday, 7AM- 7PM (Central Time) to review claim status and verify your personal information.
2. What should I do if I have received a bill from the medical provider indicating that my insurance has been rejected?
You should call the medical provider to verify your insurance information including your policy number, your insurance ID number and the claims mailing address. Claims for medical expenses incurred by students insured under the College-sponsored Student Insurance Plan MUST be submitted to UnitedHealthcare StudentResources, P. O. Box 809025, Dallas, Texas, 75380-9025, which is listed on the back of your insurance ID card. Although StudentResources is part of UnitedHealthcare, it is a standalone division with its own office dedicated to the administration of all UHCSR plans. All claims must be directed to StudentResources. Any claims that are submitted to any other UnitedHealthcare offices would be rejected because the insured would not be identifiable in their system. Once you have verified that the medical provider has the correct insurance information for you, you should request that the office resubmit the claim to UnitedHealthcare StudentResources. You should also request that they allow you an additional 30 days before payment is due on the account to allow your student insurance plan administrators to receive the claim and process in accordance with the W&M policy.
3. What should I do if I receive a bill from a medical provider in which little to nothing was paid by the insurance company?
You should find the corresponding Explanation of Benefits (EOB) or you can login to MyAccount to reprint it so that you can compare the billing statement to the EOB. Verify that all the PPO discounts and insurance payments have been applied to the bill. Next, you should review your plan brochure to determine if the claim was processed correctly by the insurance company in accordance with the W&M policy. The W&M plan has a policy deductible of $200 per person per policy year and an additional inpatient deductible of $250 per person per policy year that must be paid by the insured student first before benefits are payable by the insurance company. This is the amount of the covered medical expenses that must be paid first by the student before the insurance company will begin paying benefits. This may be why all or part of the bill is payable by you rather than by the insurance company. If there is an error in how the claim was processed, you should contact Customer Service at (800) 767-0700 Monday through Friday, 7AM- 7PM (Central Time) to file a complaint and request that they reprocess it in accordance with the W&M policy.
4. What should I do if I receive an Explanation of Benefits (EOB) in which benefits that I believe should be payable have been denied?
The first thing you should do is look at your current plan brochure specifically the Schedule of Benefits and the Exclusions & Limitations list to determine if your understanding of the W&M policy are correct and the denied service should have been covered by the W&M plan. The W&M insurance plan does contain certain policy provisions, exclusions, limitations or benefit maximums of which you may not be aware. If you believe that the claim has been denied in error and should be payable under the W&M plan benefits and policy provisions, then you should call Customer Service at (800) 767-0700 to file a complaint or an appeal. You may be required to submit a formal appeal in writing to the insurance company, which will make a thorough investigation and respond to the complaint in a timely manner. If you do not agree with the results of the claims review, you may appeal further to the Special Investigations Unit of UnitedHealthcare StudentResources, which utilizes external medical consultants who will review the medical records and make a recommendation to the insurance company based on their medical judgment. Again, you will be notified of the response in a timely manner. After appeals for denied coverage have been through all levels of the insurance company's internal process and if you are unable to obtain satisfaction from UHCSR, you may contact the Virginia State Corporation Commission, Life and Health Division, Bureau of Insurance by mail at P. O. Box 1157, Richmond, Virginia, 23218 or by phone at (804) 371-9691 or toll-free at (800) 522-7945 (in-state) or (877) 310-6560 (out-of-state).