Umr Ez Claim PDF Details

When it comes to managing healthcare benefits and ensuring that medical/vision claims are processed efficiently, understanding the UMR EZ Claim Form is crucial for employees. This form serves as a conduit between patients, healthcare providers, and insurance carriers, aiming to streamline the submission of medical or vision claims. Required information includes the employer's name, group number, and the member's identification details, alongside patient specifics such as name and date of birth. The form meticulously asks if the claim is related to an accident, prompting for detailed accounts if applicable, and queries about coverage under another group plan, which could affect the processing of the claim. Vital for the processing of any claim are particulars such as the date of service, diagnosis and procedure codes, provider’s tax identification number, and billed charges, ensuring transparency and accuracy in the claims process. Additionally, the form directs claimants to attach prescription receipts or physician statements as necessary, and to indicate whom the issue payment should be made out to. With options for submission via mail or email, the UMR EZ Claim Form embodies an essential step in accessing entitled medical or vision benefits, emphasizing the importance of detailed and precise information submission for both employees and dependents seeking coverage reimbursements.

QuestionAnswer
Form NameUmr Ez Claim
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessubmit umr claim, umr claim submission form, umr claim form vision, umr member claim submission form

Form Preview Example

EZ Claim Form Medical/Vision

Name of Employer: ________________________________ Group #: ____________________

Name of Employee: _______________________________ Member ID#: ________________

Patient’s Name: _____________________________________ Date of Birth: ____/____/____

(Last Name, First, Middle Initial)

Is claim related to an accident:

No

Yes

If yes, provide details including date, description and location of accident

____________________________________________________________________

Is patient covered by another group plan?

No

Yes

If yes, type of other coverage:

Medical

Dental

Vision

Carrier: ______________________________________________________________

Group Number: _____________________ Employee Name: ____________________

ID Number: ____________________ Name of Employer: _______________________

Please attach your prescription receipts and physician’s statement.

THE FOLLOWING INFORMATION MUST BE ON YOUR RECEIPT OR ON YOUR PROVIDER INVOICE AND SUBMITTED WITH THIS CLAIM FORM IN ORDER TO PROCESS YOUR CLAIM (PLEASE CHECK EACH BOX):

Cash register receipts or cancelled checks are not an acceptable claim.

Date of Service

Diagnosis Code

CPT (procedure) Code

Provider Tax Identification Number (TIN)

Provider Name

Billed Charges and Amount Paid

.

For prescription claims please provide a copy of the drug receipt, outlining name of the pharmacy, drug, Rx number and date purchased.

Issue Payment to:

Provider or

Employee

_____________________________________________________

_______________________

(Employee’s Signature)

 

(Date)

$VDPHPEHU\RXPD\VXEPLW\RXUFODLPWR80 E\RQHRIWKHIROORZLQJPHWKRGV

)D[FODLPVWRMail the claims to:

Email a .pdf of your claim to:

855-444-2896

UMR

umr-claimsubmission@umr.com

 

PO Box 30541

 

 

Salt Lake City, UT 84130-0541

 

How to Edit Umr Ez Claim Online for Free

It really is not hard to fill in the umr claims forms. Our PDF editor was developed to be easy-to-use and let you complete any PDF quickly. These are the four actions to follow:

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stage 1 to writing submit umr claim

You have to prepare the THE FOLLOWING INFORMATION MUST BE, Date of Service CPT procedure Code, Diagnosis Code Provider Tax, For prescription claims please, Issue Payment to Provider or, Employee, Employees Signature, Date, and cid field with the essential particulars.

submit umr claim THE FOLLOWING INFORMATION MUST BE, Date of Service CPT procedure Code, Diagnosis Code Provider Tax, For prescription claims please, Issue Payment to Provider or, Employee, Employees Signature, Date, and cid blanks to insert

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