EFTA00301534.pdf

UnitedHealthcare A UnitedHealth Group Company September 8, 2015 Jeffrey Epstein 6100 Red Hook Quarter B-3 St Thomas, VI 00802 Policy: Policy Name: SOUTHERN TRUST COMPANY Policyholder: Jeffrey Epstein Dependents: Subscriber ID: Effective Date of Coverage: 05/01/2014 - current To Whom It May Concern: 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 require coordination by a Participating Physician and Prior Authorization (Care Coordination @1-800-638-7204) of the plan. If you have any questions, please contact the Customer Service Center at 800-357-0978. We are available to assist you between the hours of 8:00 a.m. and 8:00 p.m., EST, Monday through Friday. See attached International Claims Transmittal form with instructions on how to submit out of country claims for reimbursement. Sincerely, Customer Response Group EFTA00301534 International Claims Transmittal UnitedHealthcare I UmedisakhCrow)ConPari Return this form with the original medical bill or claim form via mail to: UnitedHealth Group International Claims PO Box 740817 Atlanta, GA 30374 Fax: (8C1)938-2_05 Please complete all sections of this ITOIlsminal jam. Claims mutt 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 proce" the claim. You will be advised in writing should additional information be required. • Check here if this is a repeat submission • Each patient Please complete a new & separate claim transmittal form for: • Each inpatient hospital stay • Each different healthcare provider • Each currency type Section 1 — Member Sr Patient Information Check one: I am an Expatriate or retiree hying abroad_ I am traveling internationally for pleasure. I am traveling internationally for business. however. live in the U.S. Group Name Group Policy tr Member Name Member id Patient Name Patient Relationship Patient Date of Buth Member Phone 0 Member's Return Correspondence Address Street Town/city 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 0 Emergency room visit 0 Lab or X-ray services 3 Prescription drugs covered under your UHC plan 0 Medical supplies 0 Other A brief explanation of the purpose of your healthcare provider visit: Including terraces rendered anthor procedures performed: Section — Healthcare Provider Contact Information Name of Healthcare Provider Name of facility or hospital Address Street Town/city Area postal code Region Country Telephone number (including 2- digit country code) Fax number (if available) Continued on reler:e ;id( EFTA00301535 International Claims Transmittal UnitedHealthcare tkitc4Heath Guy Compary 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 and/or 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 www.myufic.com. Please use this as a resource when checking the status of your claim. • If a reasonable amount of time has passed. and after checking www.myuhc.com 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. EFTA00301536