EFTA00296355.pdf

UnitedHealthcare September 8, 2015 Jeffrey Epstein 6100 Red Hook Quarter B-3 St Thomas, VI 00802 Policy: Policy Name: Policyholder: Dependents: Subscriber ID: Effective Date of Coverage: To Whom It May Concern: i SM A UnitedHealth Group Company 0272605 SOUTHERN TRUST COMPANY Jeffrey Epstein N/A 854905597 05/01/2014 - current This is to verify that the individual(s) listed above is currently covered under this group health policy. Covered individuals have coverage outside the United States for Emergencies only. Emergency, as defined in your certificate of coverage is a serious medical condition resulting from injury, sickness or mental illness which arises suddenly and requires immediate care and treatment, generally received within 24 hours of onset, to avoid jeopardy to the life or health of a Covered Person. The charges for treatment must meet clinical guidelines for a non-work related illness or injury and incurred while you are covered under this policy. It is the insured's responsibility to pay for all related medical services. Incurred expenses should be submitted to the medical claims office for reimbursement. All services are subject to contract provisions and limitations. In case of an emergency, you must notify the plan within 48 hours after the Emergency health Service are initially provided or soon thereafter as is reasonably possible. You must make available full details of the Emergency Health Services received at the request of the Plan. Continuation of care after the condition no longer is an emergency shall re uire coordination by a Participating Physician and Prior Authorization (Care Coordination O1-I of the plan. If you have any questions, please contact the Customer Service Center at assist you between the hours of 8:00 a.m. and 8:00 p.m., EST, Monday through Friday. We are available to See attached International Claims Transmittal form with instructions on how to submit out of country claims for reimbursement. Sincerely, Customer Response Group EFTA00296355 International Claims Transmittal UnitedHealthcare Return this form with the original medical bill or claim form via mail to: United}hal& Group International Claims PO Box 740817 At Fa • Check here if this is a repeat submission Pink, complete all sections of this nonsminal joint. Claims arm, be delayed if all sections of this form are not completed. However, this does not guarantee that additional information will not be requested from you to procen the claim You will be advised in writing should additional information be required. Please complete a new & separate claim transmittal form for: • Each patient * Each inpatient hospital stay • Each different healthcare provider • Each currency erpe Section 1 — Member & Patient Information Check one: I am an Expatriate or retiree Irving abroad_ I am traveling internationally for pleasure. I am traveling internationally for business. however. live in the U.S. Group Name Group Policy Member Name Member id i Patient Name Patient Relationship Patient Date of Birth Member Phone Member's Return Correspondence Address Street Towttraty Area postal code Region Country In which country did the treatment take place? What type of currency is the bill submitted in? What is the total amount of the claim in U.S.Dollars? (opt) Please check the type of service that was rendered: 3 Office visit 3 Inpatient hospital care 3 Inpatient surgery 3 Outpatient surgery 3 Emergency room visit 3 Lab or X-ray services 3 Prescription drugs covered under your UHC plan 3 Medical supplies 3 Other A brief explanation of the purpose of your healthcare provider visit: including services rendered ancVor procedures performed, Section - Healthcare Provider Contact Information Name of Healthcare Provider Name of facility or hospital Address Street Townictry Area postal code Region Country Telephone number (including ?- digit country code) Fax number (if available) Continued on ro ep:e ;ide EFTA00296356 International Claims Transmittal UnitedHealthcare Ii aUrtedleaMhGroupCompany Section 3 — Important Information for Submitting Your Medical Claim • Faxing - Illegible faxes received in our mailroom will be returned to you via the fax number used to send the document to us. Therefore. when faxing correspondence to us, please make sure you use a fax machine where you can also receive correspondence. • Submitting original documents is always helpful in expediting the processing of your claim. When possible. send the original claim, itemized bill. and medical records. This is especially helpful for inpatient hospital bills. • If possible, ask the provider of service to write the bill in English and convert the currency to U.S. Dollars. • If the provider of service is not able to present the bill or claim in English and U.S. Dollars. do not perform the translation or currency exchange yourself. United Healthcare will provide these services for you. • Remember that all plan-filing rules apply to international claims. Submit your claims as soon as possible after treatment is rendered. • If payment is to be issued to you. please submit a proof of payment. A cancelled check. cash receipt. charge receipt. or handwritten receipt from the medical provider is acceptable. • If you have a U.S. address for the receipt of mail. please make sure that your employer is aware of this address so they may supply it to us for the mailing of your check andior explanation of benefits. • International bills can be more complicated than a regular U.S. bill due to language and currency conversion and/or the receipt of additional information required to process the claim. As a result. it may take longer to process your claim. • Your international claim payment information is available on when checking the status of your claim. Please use this as a resource • If a reasonable amount of time has passed. and after checking for the status of your claim. you still have questions regarding the status or payment of your claim. please call the Member Services number on the back of your ID card. Note for non-medical or non-UHC claims (ie: Dental, Medco Rx, etc.) — this is not the process for submitting your international bill. Please contact the Member Services number located on the applicable member id card. EFTA00296357