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Adelphi Insurance

This document is a health plan ID card for Sunom Chyyo Sada, a member of UnitedHealthcare Student Resources for the 2024-25 academic year. It includes essential information about the member's coverage, instructions for accessing benefits, and claims submission details. The card also provides contact information for customer service and emergency assistance while traveling.

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sunomsada12
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15 views

Adelphi Insurance

This document is a health plan ID card for Sunom Chyyo Sada, a member of UnitedHealthcare Student Resources for the 2024-25 academic year. It includes essential information about the member's coverage, instructions for accessing benefits, and claims submission details. The card also provides contact information for customer service and emergency assistance while traveling.

Uploaded by

sunomsada12
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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7

October 16, 2024

757 @@Barcode@@
Sunom Chyyo Sada
31 LAWRENCE ST
Uniondale, NY 11553

Thank you for being a UnitedHealthcare Student Resources member.

We're glad you're here.

This is your UnitedHealthcare health plan ID card. It has information about you and your coverage so you'll want to take it
with you wherever you go.

Please be sure all the information on your ID card is correct. Call us using the toll-free member number on your ID card if any
information is not correct or you need assistance. You can start using your ID card on your effective date.

To get the most of out of your plan, follow these steps:

1. Get access on the go.


Create your My Account at www.uhcsr.com/myaccount. Our mobile friendly website will help you:
- Find and estimate the cost of the care you need.
- See what's covered and get information about any additional benefits available to you.
- View claim details and account balances and much more.

2. Check out our videos page.


www.UHCSR.com/video has many informative videos on how to access and utilize key elements in your My Account, as well
as a large library of mental health videos provided by Psych Hub.

3. Know your network.


With almost every plan, you'll pay less if you choose doctors, clinics and hospitals in your network. Search for network providers
on www.uhcsr.com or the UHCSR mobile app.

STD (4/24)

2024-25 Academic Year CLAIMS INSTRUCTIONS


Submit claims to the company within 90 days or as required by state law after the date of
Insured: Sunom Chyyo Sada service. Mail all medical bills along with the insured student's name, patient's name, SR
SR ID #: 9406059 Policy # (80840): 2024-757-1 ID number, address, and plan name to the address listed below.
Plan Name: Adelphi University
Send claims to: For emergencies while traveling call:
Members: Customer Service Providers: Customer Service Student Resources UnitedHealthcare Global
1-866-948-8472 1-888-224-4875
P.O. Box 809025 1-877-461-2273 (Toll-free) or l-4!0-453-6330
Copays: $35 OV; $75 Urgent Care; $250 ER Dallas, TX 75380-9025 or email: assistance@ubcglobal.com
EDI Payer ID: 74227 ID#: 355751
DED IND/FAM OOPM IND/FAM Rx Bin: 610279
INN: $250/ INN: $8500/ Rx PCN: 9999
OON: $500/ OON: $17000/ Rx Group: UHCSTRC01 For Hospital pre-admission notification call UnitedHealthcare at 1-877-295-0720.
RX Copays: INN: $25 Tier 1;
$60 Tier 2; $75 Tier 3 NOTICE TO ALL HEALTHCARE PROVIDERS
FULLY INSURED
This card is not a guarantee of coverage. For information concerning coverage, co-payment and
UnitedHealthcare Choice Plus PPO claims instructions, please call Customer Service at the number listed on the front of this card.
ID1:24S Underwritten by UnitedHealthcare Insurance Company of New York 23-IDI www.uhcsr.com

23-ID1

L _J

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