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Forms – St. John’s 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.

 

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.

 

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.

Prescription Drug Information – St. John’s University

OptumRx

As a UnitedHealthcare member, you have access to a comprehensive and quality pharmacy benefit provided through the UnitedHealthcare Pharmacy Benefit Program. UnitedHealthcare uses OptumRx. (www.optumrx.com) for certain pharmacy benefit services including your mail order benefit.

 

Make Informed Decisions

When selecting a medication, you and your doctor should consult the UnitedHealthcare Prescription Drug List (PDL). The PDL includes most brand and generic medications approved by the FDA. Medications may be placed on different “tiers” based on their overall value, with Tier 1 being the most affordable tier option. Click below to download and review the current Prescription Drug List:

Prescription Drug List

To determine if a medication is covered by your pharmacy benefit, its tier level, and available lower cost alternatives log in to My Account.

After you log into My Account, you can access:

  • Payment, pricing, and coverage information about most prescription medications
  • Information about lower cost medication alternatives,
  • A list of participating retail pharmacies by ZIP code, and
  • Your prescription history

Choose a pharmacy that’s in the network

To get the most from your pharmacy benefit, you should use a participating retail pharmacy. There are over 60,000 retail pharmacies in our network, including both chain and independent stores located across the United States.

Use the Pharmacy Locator to find a participating retail pharmacy.

Participating Pharmacy Chains

If you had to pay out of pocket for a prescription and need to receive a reimbursement please download the prescription claim form:

Filling prescriptions at pharmacies outside our network will increase your cost.

To get prescription drug information please call 1-855-828-7716.

Access the OptumRx Member FAQÂ for more information. Mail order benefits included only when applicable in your policy brochure.

Find a Doctor – St. John’s 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 1-888-251-6253 and/or by asking the provider.

The Preferred Provider for your plan is UnitedHealthcare Options 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:

Travel Assistance, Evacuation & Repatriation – St. John’s University

 

Global Emergency Services (GES)

Have some peace of mind while traveling. We’ve heard great stories about GES saving the day for students who are studying or traveling in other states or other countries. When you’re at least 100 miles from home and you’re sick or hurt, GES steps in with immediate assistance and evacuation benefits. They can even help you get home if you need to be medically evacuated.

Some benefits of this service include:

  • Emergency Medical Evacuation
  • Dispatch of Doctors/Specialists
  • Medical Repatriation
  • Transportation after Stabilization
  • Transportation to Join a Hospital Insured Person
  • Return of Minor Children
  • Repatriation of Remains
  • May also include additional assistance services to support your medical needs, including worldwide medical referrals and medication/vaccine transfers.
  • Contact information is on the back of your SR ID card or in My Account

 

For more information on Global Emergency Services, please review the Assistance and Evacuation Benefits section in your Brochure-Certificate.

Health Care 101 – St. John’s University

Welcome to the Health Care 101 Center! We understand the busy schedule of both parents and kids, no matter what the age. With that in mind, here’s a no-frills, easy-access guide to health insurance benefits.

Insurance 101 is not meant to address your policy specifically (each one of these has its own list of exclusions and limitations). However, this is a generic overview of health insurance types and terminology. If you have a specific question about your policy please give us a call at 1-888-251-6253.

Trying to determine if you should purchase the health insurance plan? Download our tools below for a few tips

Healthcare 101

Insurance Glossary of Terms

Certificates & Flyers – St. John’s University

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

2022-2023 School Year | 2021-2022 School Year

2022-2023 School Year

2021 – 2022 School Year

 

 

 

Check Claim Status – St. John’s University

If you are a student and would like to check on the status of a claim that you or a provider submitted to UnitedHealthcare, you will need to set up a My Account if you have not already done so.

Please visit our My Account center to log in to an existing account or to create a new one.

File a Medical Claim – St. John’s 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.

 

Mail Claim Forms to:

UnitedHealthcare
StudentResources
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:Â 1-888-251-6253 or CONTACT US

File a Prescription Claim – St. John’s 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

Enroll Now-Health Insurance – St. John’s 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 certificate for your rates, effective dates before starting the enrollment process. The plan’s benefits can be found in the certificate within the Schedule of Benefits section with the exclusions towards the back.

2022-2023 Enrollment Information

View your school’s CERTIFICATE

Student Eligibility

International students or other persons with a current passport who: 1) are engaged in educational activities; 2) are temporarily located outside his/her home country as a non-resident alien; 3) have not obtained permanent residency status in the U.S.; and 4) are enrolled in an associate, bachelor, master or Ph.D. degree program at a university or other educational institution, with no less than 6 credit hours (unless such school’s full-time status requires less); Visiting Scholars with an F1 or J1 visa are eligible to enroll in this insurance Plan. The six credit hour requirement is waived for Summer if the applicant was enrolled in this plan as a full-time student in the immediately preceding Spring term.

The student must actively attend classes for at least the first 31 days after the date for which coverage is purchased with the exception of International Visiting Scholars. Home study, correspondence, and online courses do not fulfill the eligibility requirements that the student actively attend  classes.  The Company maintains its right to investigate  eligibility or student status and attendance records to verify that the Policy eligibility requirements have been met. If and whenever the Company discovers that the Policy eligibility requirements have not been met, its only obligation is refund of premium.

Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the student’s legal spouse and dependent children under 26 years of age.

 

U.S. citizens are not eligible for coverage as a student or a Dependent

Student/Dependent Enrollment Instructions

TO ENROLL PLEASE CLICK ON THE FOLLOWING LINK:

Please be sure to select I AGREE when you are asked if you wish to share your Insurance Information with your school in order for your school to verify if you are in compliance with their Insurance Requirements.　

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 Us for cost and enrollment information as a Qualifying Life Event.

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If you have any questions about the enrollment process, please call 1-888-251-6253 or CONTACT US

We are always happy to help in any way.

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