Claim Form


If you visit a network provider, he/she will submit your claim on your behalf. However, if you need to submit a claim for non-network services, simply print the attached form, complete the necessary information and mail it to the address on the form.

Or, you may email using UnitedHealthcare's secure email link:


Faxed claims are also acceptable and may be faxed to any of the following numbers:






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Predetermination Forms

Predeterminations are requests that services or treatments be approved before they have been received (also known as preservice claim determinations). If you would like to request a Predetermination, simply print the attached form, have the provider complete the necessary information and mail it to the address on the form.

Faxed Predeterminations are also acceptable and may be faxed to:






Travel Reminder:

It's good to know that The Empire Plan is there wherever you or your family goes.


Before you go, however, plan ahead. Do you have your doctor's phone number and your NYSHIP Empire Plan Benefit Card? Do you have enough of your regular medications? Don't forget to print this section and bring it along. It has important information and phone numbers.


Empire Plan coverage is available worldwide, and not just for emergencies. Most parts of The Empire Plan have two levels of benefits. If you use an Empire Plan participating provider, you will receive covered services and supplies at little or no cost and have no claim forms to fill out. If you use a non-participating provider, medically necessary services and/or supplies are covered, but deductibles, coinsurance and benefit limits may apply


If you require medical care while abroad, the American Embassy can usually provide names of reliable, English speaking doctors. After receiving medical services, ask for copies of your medical records in English if possible. Keep a receipt when you pay your bill. When you get home, submit the original records to the appropriate Empire Plan carrier and retain a photo copy for your records. The carriers will reimburse you directly for covered expenses. If you are Medicare Primary, remember that Medicare does not provide coverage outside the United States. The Empire Plan is primary until you return.