How to Fill Out and Submit the NYSHIP Empire Plan Claim Form

The NYSHIP Empire Plan claim form is a standard CMS-1500 health insurance form you complete and send to UnitedHealthcare, the plan’s medical and surgical administrator, whenever you’ve paid an out-of-network provider who doesn’t bill the insurer directly. Mail the completed form with an itemized bill to UnitedHealthcare, PO Box 1600, Kingston, NY 12402-1600, or upload it through the UnitedHealthcare member portal.¹ The form covers medical and surgical services only. Prescription drugs, outpatient mental health, and substance use claims each go to a different administrator on different paperwork.

When You Actually Need to File

Most Empire Plan enrollees never fill out a claim form. Participating providers bill UnitedHealthcare directly and all you see is an Explanation of Benefits in the mail. You need to file yourself when:

You saw a nonparticipating (out-of-network) provider and paid at the time of service.
You carry another health plan that pays first, and you’re submitting to the Empire Plan for the remaining covered amount.¹
You received non-hospital medical care outside the United States, which the plan treats as out-of-network.²
You bought durable medical equipment or supplies from a vendor that doesn’t bill the plan.

Where to Get the Form

The form is a CMS-1500, the standardized health insurance form used across the industry. Download it from UnitedHealthcare’s member forms portal at memberforms.uhc.com, or request one by calling 1-877-7-NYSHIP (877-769-7447) and pressing 1 for medical and surgical benefits.¹ If your provider gives you a completed CMS-1500 at checkout, you can forward that directly.

How to Fill Out the Form

Print all entries in black ink using capital letters. Don’t use commas in numbers, dollar signs, decimals, or dashes. The form is machine-scanned and special characters cause read errors. Use eight-digit dates (MM/DD/YYYY) throughout. If you make a mistake, start fresh rather than crossing anything out.³

Patient and Enrollee Identification

Box 1a takes the nine-digit insured ID number from your Empire Plan benefit card. It begins with 890 and must match the card exactly.³ Box 2 is the patient’s name (last, first, middle initial) — the person who actually received care, which may be a dependent and not the enrollee. Box 3 is the patient’s date of birth and sex. Box 4 is the enrollee’s name as it appears on the benefit card. Box 5 is the patient’s current mailing address and phone. Box 6 asks the patient’s relationship to the insured: self, spouse, child, or other. Getting box 6 wrong is one of the fastest ways to trigger a denial.

Other Insurance

If another policy also covers the patient, complete boxes 9 through 9d with that policyholder’s name, group number, and carrier name, and mark “Yes” in box 11d. If the Empire Plan is the only coverage, mark “No” in box 11d and leave the box 9 series blank.³

Accident and Employment

Boxes 10a through 10c ask whether the condition relates to employment, an auto accident, or another accident. These are required. Leaving them blank delays processing because the insurer has to establish whether workers’ compensation or auto insurance should pay first.

Diagnosis and Services

Box 21 holds the ICD-CM diagnosis codes, primary diagnosis first. Pull these from the provider’s itemized bill or superbill. Box 24 is the service grid: one row per procedure, listing the date of service, CPT procedure code, diagnosis pointer back to box 21, and the charge. You can combine identical procedure codes across no more than two consecutive dates on a single line. Box 17b takes the 10-digit NPI of the physician who referred or ordered the service.

Signature

Box 12 needs the patient’s signature or an authorized representative’s. This is what releases the medical information UnitedHealthcare needs to adjudicate the claim. Without it, the file sits.

What to Attach

The form on its own won’t get you paid. Include an itemized bill from the provider — not a balance-due statement, not a credit card receipt. It needs a line-by-line breakdown showing each service, the date, the CPT procedure code, the diagnosis code, and the charge per line, along with the provider’s name, address, tax ID, and NPI. Most providers will print you a superbill if you ask at checkout.

For durable medical equipment, the invoice has to show the item name and quantity. For international care, submit the original itemized hospital bill (translated into English if possible), and include your Empire Plan ID along with the code “YLS.”² If the Empire Plan is secondary, attach the primary insurer’s Explanation of Benefits showing what they paid.

Keep copies of everything. If UnitedHealthcare comes back asking for more documentation, or if you end up appealing, your paper trail is the only thing between you and a lost claim.

Where to Submit

Mail the completed CMS-1500 and itemized bill to:

UnitedHealthcare
PO Box 1600
Kingston, NY 12402-1600¹

To submit online, use the direct medical reimbursement form at memberforms.uhc.com/DirectMedicalReimbursement.html, which lets you enter the claim details and upload documentation without mailing anything.² You can also sign in to your UnitedHealthcare member account, go to Claims & Accounts, and choose “Submit a claim” to upload a completed form.

Once UnitedHealthcare has your submission, it reviews the claim against the plan’s rules and fee schedule and sends an Explanation of Benefits showing the total charge, the allowed amount, what the plan paid, and what you owe. Reimbursement comes as a check, or by direct deposit if you’ve enabled electronic payments through your member account.

Filing Deadline

Don’t sit on a claim. For nonparticipating provider services, the Empire Plan uses a 15-month timely filing window counted from the date of service. For a hospital stay or other multi-day service, the clock starts on the last date of service. When another insurer pays first, the clock runs from the date of that carrier’s Explanation of Payment, not the date of service. Claims received after the deadline are denied regardless of whether the care was covered.

Different Claim? Different Address

The CMS-1500 you send to UnitedHealthcare only covers medical and surgical care. Three other categories go elsewhere, and sending the wrong form to the wrong place is a common reason claims get lost.

Prescription Drugs

Prescription reimbursement goes to CVS Caremark, not UnitedHealthcare. Download the Empire Plan Prescription Drug Program Prescription Reimbursement Claim Form from nyship.ny.gov or call 1-877-7-NYSHIP and press 4. Attach original pharmacy receipts (cash register receipts don’t qualify except for diabetic supplies). Each receipt needs the patient name, prescription number, NDC number, fill date, metric quantity, total charge, days supply, and the pharmacy’s name and address or NABP number. The prescribing physician’s NPI is also required. Use a separate form for each patient.⁴ Mail to:

CVS/caremark
PO Box 52136
Phoenix, AZ 85072-2136⁴

The deadline for drug claims is 120 days after the end of the calendar year in which the prescriptions were purchased. If another plan paid first, it’s 120 days from that plan’s payment.

Mental Health and Substance Use

Outpatient mental health and substance use claims go to Carelon Behavioral Health. Use a CMS-1500 with the same formatting rules (black ink, capitals, no special characters, eight-digit dates). In the white carrier area at the top of the form, enter the patient’s name and address.³ Mail to:

Carelon Behavioral Health
PO Box 1850
Hicksville, NY 11802³

For questions, call 1-877-7-NYSHIP and press 3.

If Medicare Is Primary

Retirees enrolled in both Medicare and the Empire Plan usually don’t file anything. NYSHIP’s Medicare Crossover Program forwards processed Medicare claims to the Empire Plan’s administrators automatically. You do need to file manually when the service is covered by the Empire Plan but not by Medicare, when inpatient mental health or substance use services are involved (those don’t cross over), or when a third carrier sits between Medicare and the Empire Plan.⁵ Check your Explanation of Medicare Benefits for a “Medicare Crossover” notation; if it’s missing, call UnitedHealthcare at 1-877-7-NYSHIP (press 1) to verify enrollment.

If the Claim Is Denied

The Explanation of Benefits will state the reason. Common ones: missing documentation, services the plan considers not medically necessary, or charges above the allowed amount. Before filing a formal appeal, call UnitedHealthcare at 1-877-7-NYSHIP to see whether resubmitting with corrected paperwork fixes it. Many denials are really incomplete submissions.

If the denial stands, you have 180 days from the date of the denial notice to file a Level 1 internal appeal.⁶ Someone not involved in the original decision reviews it.⁷ You’ll get written acknowledgment within 15 days. A Level 2 appeal is available if Level 1 goes against you. Send medical and surgical appeals to:

UnitedHealthcare
Attn: Appeals
PO Box 1600
Kingston, NY 12402-1600⁶

Appeals can also be faxed to 845-336-7989. Include a letter explaining why the claim should be covered, with any supporting records from your provider.

1
New York State Department of Civil Service. Contact The Empire Plan
2
New York State Department of Civil Service. The Empire Plan Worldwide
3
Carelon Behavioral Health. Empire Plan Claim Form Instructions
4
Central Islip School District. Empire Plan Prescription Drug Program Prescription Reimbursement Claim Form
5
SUNY Geneseo. Medicare and NYSHIP
6
UnitedHealthcare. Appeal Rights
7
NYSHIP Online. Empire Plan Report