For filing out of network medical/dental claims (except prescription claims) under the Williamson County Plans forward receipt and claim form to the Claims Repricer noted in the Employee Benefits Directory located in this web page.

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For verification of benefits or inquiries on a specific claim payment, contact the Claims Administrator noted in the Employee Benefits Directory located in this web page. If you attempt to contact the Claims Administrator three (3) times and are unable to obtain a satisfactory response to your inquiry, please complete a Benefits Resolution Form and forward it to the Human Resources Department. The department's phone and fax numbers are noted in the Employee Benefits Directory located in this web page. A response will be returned to you as quickly as possible.

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1. When submitting a claim yourself, use a Claim Transmittal Form when possible. Use a separate Claim Transmittal Form for each patient. Do not submit claims for more than one person on the transmittal form.
2. Make sure the following information is on every claim:
   1. Name of the covered employee
   2. Name of the patient
   3. Social Security Number of the covered employee
   4. If the patient has the same name as another family member, make sure the patient's date of birth is listed on the claim.
   5. Who payment should go to. The physician? Employee?
   6. Date services were rendered
   7. Group name and/or group number (Williamson County #704512)
3. On claims due to an accident, please submit a brief description of the accident along with the claim. Be sure to include when & where it occurred and if other insurance coverage will be involved. All claims related to an accident will stay in a pended status until the accident details are received. If three months pass and your accident details have not been received, the claim will be denied.
4. If you have seen an in-network physician and paid an office visit co-pay, do not file the claim yourself. It is in the contract with the in-network providers, that they file the claim for you. This will prevent duplicate submissions.
5. If you are a new enrollee on the plan, be prepared to fill out a form asking for physicians you have seen in the six (6) months prior to your effective date on the plan. As soon as you receive this form, fill it out listing the name(s) and address(s) of the doctors seen and return it to our office. Claims will be pended until this information is received. If we have not received a response after three (3) requests, your claim will be denied. Upon receipt of the information from you, records will be requested from the physicians you listed. We may need your help in obtaining these records. Often copying medical records is a very low priority task in most physicians offices. They tend to be more willing to cooperate with their patient rather than the patient's insurance company. If we cannot get a response from your doctor, we may ask you to contact their office. Claims will not be paid until all information is received, so any help we can get from you helps us help you.
6. An Out-of-Area Benefit will apply if in an emergency you are taken somewhere out of your control, until you can transfer safely to a PPO facility; or the PPO provider/facility cannot provide the services needed; or if covered participant does not live within a radius of 50 miles of a PPO provider/facility. This is a manual function - United Health Care does not know when this applies based on the information provided on the claim forms. Please notify United Health Care when any of these situations arise so that this benefit can be applied to the service(s). Be prepared to give the details including date and type of service. If submitting claim yourself, you can note this information on the claim transmittal form. Also, always double check your Explanation of Benefits. If we failed to pick up the information, please contact us & we will reconsider the claim.
7. Send in your claims as you incur them. Do not wait until you have met your deductible to submit the bills.
8. There is a 12 month filing deadline. If you see a doctor on November 1, 2004, but do not file claims until December 1, 2005, the claim will be denied.
9. Always make copies of your submissions to United Health Care.

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For prescription claims, please forward to prescription claims administrator noted on the Employee Benefits Directory located in the web page.

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All enrollment and claim forms are available from the Human Resources Department or on-line below:

• HIPAA Privacy Regulations
• HIPAA Opt Out Notification
• Williamson County Enrollment / Change Form
• Dependent Child Change Notice
• Dependent Child Affidavit Add
• Dependent Child Affidavit Drop
• Dependent Grandchild Change Notice
• Dependent Grandchild Affidavit Add
• Dependent Grandchild Affidavit Drop
• Health Insurance Claim Form
• Prescription Member Reimbursement Form
• Vision Claim Form
• Dental Claim Form
• Workers' Compensation-First Report of Injury
• Infinisource Flexible Spending Claim Form 

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