UNITED HEALTHCARE
INSURANCE COMPANY
OF
THE
EMPIRE PLAN
P.O.
Date
Patient
Name
Patient
Address Line 1
Patient
Address Line 2
Dear Patient Name:
We
received the above claim for you. Before we
can process this claim, we require proof that your unmarried dependent is
enrolled full-time in an accredited secondary or preparatory school, college or
other educational institution and is otherwise not eligible for employer group
insurance coverage.
|
Please provide the
following information: |
|
Is the patient listed above a full-time
student at an accredited college or trade school? o If yes, please
provide the following information: Name
of school: _________________________________________________________________ School address:
_________________________________________________________________ Dates
of full-time enrollment: _____/_____/_____ to _____/_____/_____ o If no, please
provide the last date of attendance: _____/_____/_____ Does the patient have health coverage
through his/her own employer? o No
o Yes If yes, please provide the following
information: Name of employer:
_________________________________________________________________ Name of plan or insurance company:
_____________________________Phone: ________________ Effective date of coverage: _____/____/___ Date
when coverage may stop: _____/______/____ Is the patient married? o No
o Yes - If yes, provide date of marriage:
____/____/_____ Has the patient served in the Military? o No
o Yes - If yes, provide dates of services
____/____/____ to ____/____/____ (This may extend the patient's eligibility
period) Please
sign and mail this letter to the above return address. Subscriber's
signature: ________________________________________________________________ For
your information: ·
Full-time
student dependents continue to be eligible for coverage under the Empire Plan
until their twenty-fifth (25th) birthday. Please refer to the Empire Plan
handbook for additional information on eligibility requirements. ·
If
the patient is no longer a student, please notify your employer as soon as
possible. If the patient is disabled, ask your employer if the disability
meets the guidelines within their contract. |
Your
claim is on hold until we receive this information from you. When we receive
the information, we will process your claim within 15 days. Please respond
within 60 days or your claim will be denied.Important Note: If you
have already completed this request within the last 60 days and the student status of this
individual has not changed, you do not need to complete this questionnaire.
If
you have any questions about this letter, please call us at 1-877-7-NYSHIP
(1-877-769-7447) or write to us at the above address.
Sincerely,
OptumHealth Behavioral Solutions