CLAIM REQUIREMENTS - Please provide the following information below:
*Prescription Drug (OptumRx Drug Reimbursement Form must be completed and submitted to OptumRx by the member)
- Date of Service
- Diagnosis Code (ICD9) - Medical only
- Procedure Code (CPT & Modifier) • Proof of Payment
- Tooth #, Surface or Quadrant - Dental Only
- If Injury from a accident-Cause & Place of Accident
- Itemized Charges
- Clinic Notes from Doctor
- Fill Date
- Itemized Charges
- Name & Strength of Medication
- Quantity
- National Drug Code (NDC)
- Proof of Payment
- Prescribing Doctor Name
- Original Prescription (for Philippine Drug Claims)
Date of Service Name of Laboratory Diagnosis Code (ICD9) Procedure Code (CPT) Itemized Bill of Charges Proof of Payment
- Proof of Payment
- Date of Service
- UB04 Claim Form
- Complete Medical Report
- Itemized Bill of Charges
- Proof of Payment
Deductibles & reimbursements mustbe submitted within 90 days from the date of service. Deductibles & reimbursemsents will be processed based on contracted fees with Participating Providers or Usual Customary Rates(UCR) for Non-Participating Providers; the member is responsible for any excess charges. Claims from foreign countries must be translated to English.
AUTHORIZATION-I authorize any physician, practitioner, hospital, medical care institution, insurance carrier or any other organization, institution, person or employer that has any record or knowledge of care, treatment or advice of me, my spouse, or my children to give such information to NetCare Life & Health Insurance Co. or its representatives. Thisauthorization remains ineffect as long necessary to evaluate and or process the above claim. A photographic copy of this authorization shall be as valid as the original. I hereby certify that the above information is true, accurate and complete.