Authorizations, Referrals & Reimbursements

Claim Submission for Reimbursement

To file a claim for any eligible medical expense when your physician or other provider does not file a claim, please complete, and submit the EZ Claim Form.

To process your claim in a timely manner, please be sure all information is complete, accurate and included.

  • Print clearly in black ink, completing all required fields
  • Attach your itemized statement, or fully legible copy of the bill. Be sure to keep a copy of all documentation for your records.
  • Use a separate claim form for each healthcare professional and each family member
  • To be considered a valid claim, your bill should include the following information:
    • Patient name
    • Date of service
    • Description of service (i.e.: office visit, injection, immunization, glasses)
    • Diagnosis (Numeric code of illness or injury)
    • A charge of each service
    • Name, address, and Tax ID number of the provider (required field for services rendered in the US or US territories)
  • Claim forms can be sent to UMR via:

Specialist Referrals and Prior Authorizations

Specialist Referrals

If you are referred by your primary care provider (PCP) to a specialist, a referral must be on file with UMR. Your PCP can complete this Referral Form, and fax to UMR at 877-293-4913, or they can call the provider line at 877-233-1800 and a UMR Provider Services Team Member will complete the process. Referrals only need to be made one time, per specialist, per covered member. There are no expiration dates on these specialist referrals.

Prior Authorizations

Before you receive certain medical services or procedures, Butler’s health plan requires a doctor to confirm that the requested services are considered medically necessary under the plan. This is a prior authorization. Some services requiring prior authorization may include, but are not limited to inpatient hospitalization admissions, home health care services, oncology care and services, MRIs, MRAs and PET scans, out-patient surgeries (including colonoscopies), durable medical equipment, etc. A $500 penalty will be applied for all services rendered without prior authorization.

Your healthcare provider can complete this Prior Authorization Form and fax to UMR at 866-912-8464.