Most of the time, the medical billing/claim process runs smoothly, but occasionally this process encounters problems that may result in delayed or denied claims. This list of common claims issues is provided to give you information about how these claims issues arise and what you should do to address them.
- Haven't received an Explanation of Benefits statement within 60 days of my appointment
- My insurance has been rejected
- Little to nothing was paid by the insurance company
- Benefits that I believe should be payable have been denied
- Who can I contact if I don't understand or need assistance with the medical billing/claims process
1. I haven't received an Explanation of Benefits (EOB) statement from UHCSR within 60 days of my appointment?
Login to MyAccount, from the UnitedHealthcare StudentResources (UHCSR) home page, to determine if the Insurance Company has received the claim from the healthcare provider. You should login to your online account regularly so that you can review your claims status.
- If you find the Completed Claim under My Claims, but you didn't receive an email from the company notifying you correspondence was available for your viewing, then you should check your email spam/junk folders and consider adding email@example.com to your email contact list to ensure that you receive your electronic correspondence from the insurance company.
- If you find the Claim Being Processed under My Claims, please be patient as you should receive an EOB when the claim is completed by the Insurance Company.
- If you do not see the claim listed as being completed or processed, you should immediately contact the healthcare provider directly to verify your insurance information they have on file including the Claims mailing address and your Insurance ID number and inquire as to when the claim was submitted. Bills must be received by the Insurance Company within 90 days of service or the bills may not be considered for payment. It is your responsibility to ensure that your claims are received in a timely manner.
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.
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2. What should I do if I have received a bill from a medical provider indicating that my insurance has been rejected?
You should call the healthcare provider to verify your insurance information including your Policy Name/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 StudentResources plans. All claims must be directed to StudentResources. Any claims that are submitted to any other UnitedHealthcare offices would be rejected because the insured student would not be identifiable in their system.
Once you have verified that the healthcare 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 the UHCSR Plan Administrators to receive the claim and process in accordance with the W&M policy.
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3. What should I do if I receive a bill from a healthcare provider in which little to nothing was paid by the insurance company?
You can login to MyAccount to review or print the Explanation of Benefit (EOB) statement so that you can compare the EOB to the billing statement you received from the healthcare provider. Verify that all the PPO discounts, insurance payments, credits and adjustments have been applied to your 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 benefits and provisions. 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 satisfied before benefits are payable by the Insurance Company. The Deductible 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 your financial responsibility rather than being paid 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 appeal and request that they reprocess it in accordance with the W&M policy.
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4. What should I do if I receive an Explanation of Benefits (EOB) on 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 is 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 and/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).
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5. Something has gone wrong during the medical billing/claims handling process and I need help to make sense of it. Who should I contact?
If you have logged into your UHCSR MyAccount and reviewed "My Claims" related to the healthcare services that I recently used, but I don't understand or know how to resolve the medical billing/claim issues, is help is available? First, you can contact the UHCSR Student Insurance Coordinator at W&M who is available to help. Or you can contact UHCSR Customer Service, firstname.lastname@example.org or (800) 767-0700 Monday - Friday, 7AM-7PM Central Time.