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Forms – Arcadia University

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Personal Representative Appointment Form (PRA)/Yearly Authorization Form

If you would like a parent or another specific person to assist you with filing your claim(s) and to be able to discuss details of your claim(s) with our claim department, you will need to complete and sign this form. The Yearly Authorization Form gives us permission to discuss any and all medical conditions with your Personal Representative throughout the school year. This form is filled out once and is good for every injury/sickness for the entire school year.

 

Specific Case Authorization Form

If you would like a parent or another specific person to assist you with filing your claim and to be able to discuss details of your claim with our claim department, you will need to complete and sign this form. The Specific Case Authorization Form gives us permission to discuss only one specific medical condition with your Personal Representative, as you would specify on the form.

 

Enrollment Form(s)

  • Undergraduate Dependent Enrollment Form – Coming Soon!
  • Dependent ONLY – Enrollment Form – Coming Soon!

This is the form that you will use to sign up for the School Injury and Sickness plan. It will show you the rates, coverage periods, and any optional coverages available to you.

 

Medical Claim Form

This form can help you get reimbursed for all covered medical benefits which you have already paid out of pocket. Please keep in mind when you are requesting reimbursement:

  • Clip, do not staple, all bills to the completed form.
  • Make sure all bills or itemized receipts indicate a diagnosis code, procedure code, date of service, cost, and the provider’s tax ID number.
  • Mail claim to: UnitedHealthcare StudentResources P. O. Box 809025 Dallas, TX 75380
  • OR Fax claim to: 469-229-5625

 

Claim Information Form

Please download this form if you’ve received a request from us for more information regarding a claim submitted by your doctor or if you would like to speed up the claim process. By providing the injury/sickness information we are able to process your claim accurately and efficiently.

Mail to:
UnitedHealthcare StudentResources
PO Box 809025
Dallas, TX 75380-9025

Or fax to:Â
469-229-5625

 

Pharmacy Claim Form

This form is used for reimbursement of prescription drugs. If you did not present your ID card when you purchased your prescription out of pocket, you will need to submit this form for a refund. Along with this form for prescriptions filled at a network pharmacy, please attach the paid prescription receipt and the paid cash receipt to:

OptumRx Claims Department

P.O. Box 29044

Hot Springs, AR 71903

 

Privacy Notice

This form describes how we will obtain your written authorization prior to use or disclosure of your health information. We are required by law and committed to protecting the privacy of your health information. This form explains how we may use information about you and when we can disclose that information to others. You also have rights regarding your health information that are described in this notice.

 

Travel Assistance – UHCG Program Guide

Anytime you travel more than 100 miles from your home or to another country and experience a medical emergency, you can make a single phone call to the Operations Center for help! You call will be answered by a medically-certified crisis managers who can put in motion a vast number of emergency resources to solve any problem, 24/7.

 

UnitedHealth Allies Discount Services

This program provides discounts on a wide variety of health care services from a nationwide network of health care professionals and facilities. This booklet describes the products and services available to you at discounted rates. There is no additional charge to you for the discount program.

Find a Doctor, Hospital or Lab – Arcadia University

Welcome to the Find a Doctor, Hospital, or Lab Center! Whether you’re looking for a doctor, hospital, laboratory, or even medical equipment and supplies, we have the information you need, all located right here.

Preferred Providers are the physicians, hospitals, and other health care providers who have contracted to provide specific medical care at negotiated prices. You should always confirm the Preferred Provider is part of the network, as this can change without notice by calling the Company at 800-505-4160 and/or by asking the provider.

The Preferred Provider for your plan is UnitedHealthcare Choice Plus PPO. If care is received from a Preferred Provider, any Covered Medical Expenses will be paid at the Preferred Provider level of benefits. Reduced or lower benefits will be provided when an Out-of-Network provider is used. By using a Preferred Provider you can also save yourself some out of pocket expenses. Use this link to search for participating physicians, hospitals, facilities, medical equipment, or supplies in your local area.

 

We recognize the increased need for appropriate mental health treatment for college students. We’ve partnered with United Behavioral Health (UBH) to ensure that you have access to UBH’s network of mental health care providers and facilities. UBH partners with more than 80,000 clinicians and more than 3,500 care facilities nationwide. Clinical excellence, innovation, and a relentless commitment to the most scientifically advanced health care solutions distinguish UBH as the national leader in behavioral health. To find a local Behavioral Health provider in your area, please click the link below:

File an Appeal – Arcadia University

To file an appeal, please include the following information:

  1. Â A letter requesting an appeal to your claim(s), including your:
    • Name,
    • Address,
    • Phone number,
    • UnitedHealthcare Student ID number,
    • Date of service for your injury/sickness,
    • Claim number(s) (located on the top of your Explanation of Benefits), and
    • Email address.
  2. A copy of your Explanation of Benefits for the claim(s) in question.
  3. Medical Records including all test results from all providers visited for the specific injury/sickness that you are appealing.

Once we receive the documentation, your appeal will be reviewed and a written response will be mailed to you. The response will include what the findings were, if the appeal was approved or denied, and the reason for the final decision.

If you have a question about your claim denial, you may call our Customer Service Department at telephone number 1-800-505-4160 for further explanation to informally resolve your appeal. If you are not satisfied with our explanation of why the claim was denied, you or your authorized representative may request an internal review of the claim denial. (For more information about an authorized representative, please click on “forms” on the left.)

File a Prescription Claim – Arcadia University

If you would like to submit a paper claim for reimbursement for a prescription that you paid for out of pocket, please print a copy of the Generic Reimbursement Claim Form located below.

After filling out the necessary information, please read the acknowledgement carefully (located at the bottom of page) and sign and date in the space provided.

To submit a Generic Reimbursement Claim Form, please be sure your receipts are complete. In order for your request to be processed, all receipts must contain the information listed below:

  • Date prescription filled
  • Name and address of pharmacy
  • Doctor name or ID number
  • NDC number (drug number)
  • Name of drug and strength
  • Quantity and days’ supply
  • Prescription number (Rx number)
  • DAW (Dispense As Written)
  • Amount paid

This information can usually be found on the receipt which is stapled on the outside of the packaging or in some cases located inside. Your pharmacist can provide the necessary information as well.

Please mail completed form and receipt(s) to:

OptumRx Claims Department

P.O. Box 29044

Hot Springs, AR 71903

File a Medical Claim – Arcadia University

Submit a Claim by Mail

It’s easy! Just download the claim form below. Fill out the first page with your personal information, dates of injury or sickness, the cause of the injury or date of first symptoms for a sickness, sign your name with today’s date, and attach all receipts. Please fill out the entire first page and be sure not to leave anything blank.

Your doctor will need to fill out the second page of the form.

Mail Claim Forms to:
FIRSTSTUDENT
P.O. Box 809025
Dallas, TX 75380-9025

Medical Claim Form

Submit a Claim Electronically

Your Doctor can also submit a claim electronically using Emedeon (formerly WebMD). This gives a faster turn-around time than submitting a claim by mail. Check with your doctor to see if they are a participant. If they are, show them your ID Card. The Emedeon information is printed on the back of every ID Card.

If you have any problems filling-out these forms or would like to talk to a customer service representative, you can call us toll free at: 1-800-505-4160 or

CONTACT US

Enroll Now-Health Insurance – Arcadia University

Welcome to the Student & Dependent Enrollment Center! Here you will find all the necessary tools to enroll in your school sponsored policy.

We suggest you review the brochure for your rates, effective dates and optional coverages before starting the enrollment process. The plan’s benefits can be found in the brochure within the Schedule of Benefits section with the exclusions towards the back.

2016-2017 Enrollment InformationÂ

 View your school’s BROCHURE

Hard Waiver Student Eligibility

  • Physician Assistant Students

Will have the premium charge applied to their billing statements. If you choose to waive the University health insurance plan, this charge will be removed from your bill within ten business days. If you choose to enroll in the University health insurance plan, this charge will remain on your bill.

Begin the enrollment process by following the instructions below.

Hard Waiver Student Enrollment Instructions

Enrollment Deadlines:

  • Annual Enrollment Deadline: 6/15/16

Enroll Now

If you have missed the hard waiver enrollment deadline, but have not previously waived out of the insurance, you will be automatically enrolled in the insurance by your school, after the waiver deadline.

If you have previously waived out of the insurance but have since lost coverage due to a Qualifying Life Event please contact Riggs, Counselman, Michaels & Downes, Inc. (800) 346-4075

Please note: If you do not enroll for the year during the fall open enrollment period, you will not be able to enroll later during the 2016-2017 school year without experiencing a “Qualifying Life Event”. This means that the loss of coverage is no fault of your own or the policyholders (i.e. you get married or become too old to be on a family plan). You will be eligible to enroll within thirty days of this “Qualifying Life Event”. After thirty days, you will no longer be eligible.

Dependent Enrollment Instructions

Eligible students who do enroll may also insure their dependents. Eligible dependents are the student’s spouse and dependent children under 26 years of age. Please see the Enrollment Instructions below.

Deadlines:

  • Annual Enrollment Deadline:Â 6/15/16

Enroll by Mail

To enroll by mail-download an enrollment form and submit by mail using a check or money order. The mailing address is listed on the back of the Enrollment Forms.

The effective date of your dependent’s coverage will be start date of the coverage period you enrolled in

If you did not enroll your dependent during the annual open enrollment period but your dependent has since lost coverage due to a Qualifying Life Event please contact Riggs, Counselman, Michaels & Downes, Inc. (800) 346-4075.

Open Enrollment Periods

Open Enrollment Periods for all Dependents and Students: If you have eligible dependents in the Fall or are a student in the Fall semester and eligible to purchase coverage and you choose not to enroll for coverage before the Annual Enrollment Deadline of *June 15, 2016, you or your dependents will not be eligible to enroll again until the start of next Fall unless you experience a “Qualifying Life Event” during the year.

Qualifying Life Event

Students who did not enroll themselves or their dependent(s) during the open enrollment period may be able to enroll in the policy if they experience a Qualifying Life Event.

Qualifying Life Events include:

  • Acquiring a new family member
  • Marriage/Civil Union
  • Divorce
  • Loss or change of Job
  • Expiration of Benefits

If you and/or your dependents meet the requirements for a Qualifying Life Event, you will need to provide the following:

  • Proof of qualifying life event/proof of involuntary loss of coverage
  • Enrollment Form
  • Payment

All documents and payment must be received within 30 days of the qualifying life event. After 30 days, the student or dependents will no longer be eligible to enroll in the plan, until fall of the following school year.

Please contact Riggs, Counselman, Michaels & Downes, Inc. (800) 346-4075 Â for cost and enrollment information as a Qualifying Life Event.

If you have any questions about the enrollment process, please call 800-505-4160 or CONTACT US

We are always happy to help in any way.

Privacy Policy

Brochures, Flyers & SBC – Harcum College

Welcome to the Review Brochures Center! You will find everything you will need to know about your policy in your plan brochure such as eligibility, effective and termination dates, plan benefits, any exclusions or limitations, and instructions on how to file a claim.

2015 – 2016 School Year   |   2014 – 2015 School Year

2015 – 2016 School Year

 

2014 – 2015 School Year

 

Dental, Vision and Other Discount Services – Arcadia University

Included with most student health insurance policy is the UnitedHealth Allies discount card. To see if Student Health Allies is included with your plan, please review your brochure or check your permanent ID card.

For a complete UnitedHealth Allies brochure including Prescription Drugs, please click on the link below:

UnitedHealth Allies Brochure

We’re confident that the UnitedHealth Allies program can help you stretch your health care dollar on:

Dental Care

Save from 10% to 35% on a range of dental services including routine cleaning, x-rays, even cosmetic dentistry, such as teeth whitening.

Vision Care

Pay no more than $40 for an annual eye exam, and save 10% to 20% on eyeglasses from participating eye care professionals and retail vision chains and fittings for contact lenses (not included in annual eye exams).

Wellness products and services

Be healthier and save money with discounts of 10% to 50% on weight management, fitness memberships and equipment, relaxation resources, natural products, and vitamins and supplements. For a complete UnitedHealth Allies brochure on Dental Care, Vision Care, and Wellness Products and Services please click on the link below:

Prescription drugs

Save at the pharmacy or through the mail. Not available on plans that utilize the UnitedHealthcare Network Pharmacy Program (Medco).

Your UnitedHealth Allies ID card will be delivered along with your student health insurance ID card. Once received, log onto WWW.SR.UNITEDHEALTHALLIES.COM, and register to begin using the program immediately.

 

UnitedHealth Allies is not insurance. UnitedHealth Allies provides discounts at certain health care providers for medical services. UnitedHealth Allies does not make payments directly to the providers of medical services. The program member is obligated to pay for all health care services, but will receive a discount from those healthcare providers who have contracted with the discount plan organization.

 

Brochures, Flyers & SBC – Gwynedd Mercy University

Welcome to the Review Brochures Center! You will find everything you will need to know about your policy in your plan brochure such as eligibility, effective and termination dates, plan benefits, any exclusions or limitations, and instructions on how to file a claim.

2016 – 2017 School Year  |   2015 – 2016 School Year

 

2016 – 2017 School Year

 

2015 – 2016 School Year

 

 

Brochures, Flyers & SBC – Guilford College

Welcome to the Review Brochures Center! You will find everything you will need to know about your policy in your plan brochure such as eligibility, effective and termination dates, plan benefits, any exclusions or limitations, and instructions on how to file a claim.

2015 – 2016 School Year

2015 – 2016 School Year

 

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