HIPAA Authorization Form– UnitedHealthcare is not authorized to release protected health information without your consent. In most instances verbal authorization can be given to our insurance agent, Milestone Benefits Agency, Inc., for them to assist you or your dependent. However, in certain instances written authorization must be given to United Healthcare. If you want to authorize someone to have access to your information you must complete this form and send it to UnitedHealthcare.

As referenced above, network providers are responsible for submitting any claim forms to UnitedHealthcare on your behalf. However, if you have services provided by a non-network provider, you will need to pay that provider directly and complete the claim forms below for any reimbursements.

Prescription Mail Order Form – Complete this form and attach your prescription to receive up to a 90 day supply of your maintenance prescription medications.

Non-Network claim forms – Forms to be completed for non-network reimbursement (Not necessary for in-network services which are submitted directly by the provider)

• Non-Network Medical Claim Form
• Non-Network Prescription Claim Form

United Healthcare Website: www.uhc.com

Medical Questions: 866.844.4864
Retail and Mailorder Rx Questions: 855.842.6337
Specialty Rx Questions: 888-739-5820

Real Appeal – Free weight loss program for you and your enrolled spouse.

Medical Plan Information:

Online Provider Lookup – (Select the “UnitedHealthcare Choice Plus” as the health plan or call UHC directly)

Treatment Cost Estimator – Video on UHC’s tools for estimating and comparing the costs of your procedures.

myuhc.com–UHC’s member and consumer self-service web site that provides a single source for online benefits and health related information. Access your personalized health care and benefits information. You may also take advantage of UHC’s online pharmacy for convenient services such as home delivery of prescriptions, over-the-counter medications and other health products can be sent right to your home. (Registration available to individuals currently enrolled with UnitedHealthcare.)

Virtual Visits – FREE SERVICE!!! – See and talk to a doctor from your mobile device or computer without an appointment.  Doctors can send a prescription to the pharmacy of your choice.  Ideal for treating non-emergency conditions for things like: Bronchitis, Colds/flu, Diarrhea, Pink eye, Sinus Infections and sore throats.

Where should I go for care – A summary guide of when it’s appropriate to go to your doctor’s office, virtual doctor, convenience care clinic, urgent care or emergency room.

Preventive Care Guidelines – Summary of the immunizations, screenings and other checkups for children and adults.

Health4Me – UHC’s mobile Smart Phone app. Find a network provider, view your ID card and other features on the go.

Health Risk Assessment and Coaching – Access instructions to the Health Assessment and online coaching programs for you and your covered spouse.

UHC Annual Rights & Resource Disclosure Notice – Information about your plan with UHC, your rights, how they use of your financial information, where to receive care other other generalities.

Healthy Pregnancy – Designed for expectant mothers to keep themselves and their babies healthy. The program helps determine if there are any high-risk factors and provides general health guidelines on child development.

FAQ’s for at home COVID testing starting 1-15-22 – Information on how to get free at home COVID tests for you and your covered dependents.

Prescription Drug Information:

Prescription Drug Listing Effective: 5/1/23 and 1/1/23 (Subject to future changes) – See which drugs are covered, their copay tier, if they’re subject to prior authorizations, step therapy, etc.

Managing Pharmacy Benefits Online – Enables you to find lower-cost alternatives, refill mail prescriptions, view claim history and more

Drug Pricing information through myuhc.com – Instructions on how to check the cost of medications before you get them filled.

Dental Claim Form – In-network dentists will complete and send your claims to Delta Dental on your behalf. However, if you use a non-network dentist you may have to pay up front, complete this form and send it to Delta Dental at the address below:

Delta Dental of Ohio
P.O. Box 9085
Farmington Hills, MI 48333-9085

Delta Dental Website: www.deltadentaloh.com

Customer Service Phone: 800-524-0149

Member Portal – Online access to your claims, online ID cards, Explanation of Benefits (EOB’s), deductibles, usage levels and more.  See Flyer for more details.

Online Provider Lookup – Be sure to select either the “Delta Dental PPO” or “Delta Dental Premier” network.

How to use your Delta Dental Benefits – Information on how to find a participating dentist, telephonic and online resources, claims submissions, etc.

Reference ID cards – Delta Dental does not provide personalized ID cards but these can be printed and given to your dentist when you visit them.

Other helpful information and flyers:

• Apple and Android app information for your smart phone
• Easy Reference Card to Delta’s telephonic service inquiry system
• How benefits coordinate with other dental insurance
• How Delta Dental pays for orthodontic services

Non-Network Claim Form– In-network vision providers will complete and send your claims to EyeMed on your behalf. However, if you use a non-network vision provider you may have to pay up front, complete this form and send it to EyeMed:

Member Login: Access benefits, claims and other information about your benefits

EyeMed Customer Service Phone: 866.939.3633

Online Provider Lookup – Choose the “Select” Network when prompted.

Miscellaneous Information:

• Phone App – Access your vision benefits anytime using your smart phone.
• Special Offers – Ways you can save money and maximize the value of your benefits.

Evidence of Insurability – For late enrollees or those electing coverage amounts in excess of the Guarantee Issue levels.

Conversion and Portability – When you leave CYT – Ohio Plant, you have up to 30 days from your date of termination, to convert (Conversion Application) the group or supplemental term life insurance to an individual whole life plan.  You can also “Port” (Portability Application) your supplemental term life insurance.  This allows you to maintain the coverage as a term life benefit which is typically less expensive but increases in cost over time.

Other Forms and Information:

• Life Accident Claim Form
• Accelerated Death Benefit Form
• Waiver of Premium Claim Form

In the event a claim needs to be filed, please contact Juanita Thompson in Human Resources.

How to file a claim: Since CYT – Ohio Plant provides both a Short and Long Term Disability benefit, all claims begin under the Short Term Disability benefit. To initiate a disability claim, follow the steps outlined in this link:

Filing a New STD Claim:

Step1: Notify your supervisor
Step2: Call Mutual of Omaha at 800.877.5176 Opt.1
Step3: Take forms to your doctors

If it appears your disability will extend beyond 90 days, your STD case worker will contact you and your physician to assist you with the LTD application process. In all cases, you must contact the Administration department and your supervisor to notify them of your status. You must also complete the Waiver of Premium Claim Form so your LTD benefits and premiums can continue without any further premium payments.

Check on the status of your claim call Mutual of Omaha at 800.877.5176 Opt.1

There are three ways to get reimbursed for qualified expenses:

1. UHC covered medical services – If a service is covered under the UHC medical plan then UHC automatically sends processed claims to their FSA unit for processing. There is nothing you need to do and the check will be send directly to you. If you don’t want UHC to do this you can go into myuhc.com and remove this function.
2. UHC covered pharmacy medications – Use the debit at your pharmacy to have the money automatically deducted from your FSA.  This card is mailed directly to your home within two to three weeks after you enroll. 
3. Other medical care allowed expenses – If you have a service which is not covered by the UHC plan (i.e., dental expenses, over the counter prescriptions, etc.) then you must complete a UHC Claim Form and mail or fax it to UHC at the address indicated on the form.

Below are links to the claim forms for the three Aflac Products.

Up to $20,000 of Critical Illness coverage is “Guarantee Issue”.  However, if you elect more than $20,000, you must complete Aflac’s Evidence of Insurability form and be approved.

The forms can be submitted by fax to 866.849.2970 or via e-mail to groupclaimfiling@aflac.com 

• Accident
• Accident Wellness Benefit
• Critical Illness 
• Critical Illness Health Screening Benefit
• Hospitalization

Aflac Customer Service: 800.433.3036

Enrollment elections, changes and terminations should be made in Kronos.  However, if you have any questions about the plans during enrollment or throughout the year, you can contact Amber Stein at Aflac directly at:

Phone: (740) 815-8440
E-mail: amber_stein@us.aflac.com

Location:

CYT – Ohio Plant Clinic
573 West Main Street
Cardington, OH 43315
Phone: 419-864-0272