Claim Submission Instructions

If you go to an Empire Plan participating provider, MPN Network provider, or a MultiPlan provider, all you have to do is ensure that the provider has accurate and up-to-date personal information (name, address, health insurance identification number, signature) needed to complete the claim form. Your Empire Plan participating provider, MPN Network provider, HCAP-approved provider or MultiPlan Program provider fills out the claim form and sends it directly to UnitedHealthcare. The claim forms are available in each provider's office.

Faxed claims are also acceptable and may be faxed to any of the following numbers:
845-336-7989
845-336-7747
845-336-7716

New York State Out-of-Network Services Surprise Bill Assignment of Benefits Form