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Click ‘Get Form’ to open the UPMC Out of Network Claim Form in our editor.
Begin by filling out the Member Information section. Enter your name, date of birth, and UPMC for Life ID number. If you have a new address, make sure to check the corresponding box and provide your street address, city, state, and zip code.
Next, move to the Provider Information section. Input the provider's name, street address, city, state, zip code, and phone number.
Once all fields are completed, review your entries for accuracy. Then print the form if necessary.
Sign and date the claim form at the designated area.
Attach a 'super bill' or itemized receipt that details the services received and mail it to OptiCare Managed Vision at the provided address.
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The document you are about to read emerged from a systematic process of inquiry and intentionality about some of the most critical issues in health care.Read more
Sign Section 7 if you wish to have benefits paid directly to the doctor who treated you. UPMC Health Plan will reimburse eligible expenses only. Refer to yourRead more
Reimbursement Claim Form by calling our. Health Care Concierge team at the phone number listed on the back of your member ID card or by logging into UPMCRead more
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