Claims Frequently Asked Questions

Where can I find a claim form? 
Most times your provider will file your claim for you so a claim form is not necessary. Some claim forms are located on in the Forms section. Also, claim forms are generally available on the healthcare vendor’s website along with information on filing a claim.

How do we determine which parent's plan is primary when children are covered by both?
If both you and your spouse are employed and have healthcare coverage, you determine whether or not you want your children covered by you, your spouse or both of you. When a child is covered under more than one policy, the policy of the parent whose birthday occurs earliest in the year will be the primary policy. The other policy will consider charges as secondary and coordinate benefits. When both parents are Caterpillar employees, the children will be covered as dependents under only one parent’s policy. It is your decision under which Caterpillar employee's coverage you elect to enroll your children.

If I keep my spouse on my insurance for secondary coverage, will the insurance cover her copay on her insurance, e.g. My spouses insurance pays 90/10, will UHC pay the 10% she owes her insurance company?
The Caterpillar plan coordinates benefits with other coverage using a non-duplication methodology. The Caterpillar plan will never pay more than it would have paid in the absence of other coverage. Secondary coverage is allowed up to the co-insurance limit for the plan. Therefore, if the spouse's insurance has already paid 90% on a claim, it exceeds the 80% plan co-insurance level for the Caterpillar plan and nothing additional would be paid on the claim.

If I have a claim that I feel has been processed incorrectly, what should I do?

The first step in reviewing how your healthcare claim was processed is to review your Summary Plan Description (SPD) to understand your plan benefits. Next, review your Explanation of Benefits (EOB) delivered by mail or online at the UnitedHealthcare or Blue Cross Blue Shield websites.

If you feel your claim has been processed incorrectly, call the UHC or BCBS customer service phone number on the back of your ID card. The customer service representative will clarify the payment, and if necessary, send it to be reviewed.

When I call UHC or BCBS and they send my claim back to be reviewed, is that the same as an appeal?
No. When you call your insurance carrier, the customer service representative will review your claim and verify whether the claim has been processed correctly. If the first line representative is not able to make that determination, the representative may transfer you to a second level representative for confirmation. If the review results in a different benefit calculation, your claim will be sent for adjustment and you and your provider will receive a corrected Explanation of Benefits (EOB) along with the additional benefit if due. If you do not agree with the customer service representative's determination you may file a formal appeal.

Information on how to file an appeal can be found on your EOB.

How does the appeal process work?
If you are enrolled in a plan administered by UHC, you can submit your claim Appeal in writing or online after logging in to

If you do not need to send supporting documentation, it's recommended that you submit your appeal online. To appeal your claim in writing, complete and submit the Member Service Request Form found on > Claims & Accounts tab > Appeals and Grievances. 

When completing the Member Service Request Form, be sure to complete the "Reason for request" section. Attach a copy of your health statement or EOB for each claim. You may obtain a copy of your EOBs on If you are submitting additional information requested by UHC, attach a copy of the letter requesting this information, if available. If you have other documentation or items that may help UHC understand your request or better explain your situation, such as medical files, operative reports, or a supporting narrative of the service, attach these items also. 

Once UHC receives your request for review, an appeals coordinator will be assigned to conduct a full and fair review within the timeframe required by law.

How long do I have to formally appeal a claim payment?

Under federal guidelines, you have 180 days after you receive the denial of the claim in question to initiate the claim appeal process.

How long will it take for me to get a response on the formal appeal process?

Your healthcare vendor will respond according to requirements as cited under federal legislation. Please make sure to include copies of any documentation (EOB, claim, documentation of benefit coverage) with your appeal letter. The required timeframes may be extended if your healthcare vendor does not have the proper documentation to make a correct decision or resolution. Contact your healthcare vendor for additional information.

Can the customer services representative tell me how to file an appeal?

If you are enrolled in a plan administered by UHC, the UHC customer services rep can advise you of the appeals process at 1-866-228-4215. The appeal process is also outlined on the back of your Explanation of Benefits (EOB) statement and on

If you are enrolled in the BCBS EPO, contact the plan at the number on your ID card or log on to for information about filing an appeal.