INSURER FILING GUIDE

Oxford Health Plans, New Jersey, Connecticut and ASO any state

Use this public information to prepare your packet, then confirm the route on the insurer's own page.

AT A GLANCE

Claim facts

Member form	Oxford Medical Claim Form Number: 19-11958 12049 R2 Revision: 8/19 Open the insurer form
Portal upload	NO
Portal path	NOT APPLICABLE: Oxford form directs the completed claim and attachments to an offline route
Mail address	PLAN-DEPENDENT: Mail it to the address listed on the back of your health plan ID card.
Fax	Not published by the insurer
Attachments	Patient name; dates of service; ICD-10 diagnosis codes; CPT or HCPC procedure codes with modifiers; units; billed amount for each procedure; place of service; provider name; provider address; service address; NPI; Tax ID; group or facility name
Deadline	Not published by the insurer: controlling COC or SPD determines the claim deadline
Outcome and status	Myuhc.com EOB and claim view; UnitedHealthcare app shows claims
Processing time	Not published by the insurer: UnitedHealthcare says many claims process within 14 business days but does not identify an Oxford-specific time
Caveats	Some Oxford plans do not cover out-of-network care; New Jersey and Connecticut fully insured rules differ from ASO and self-funded plan terms; Medicare Advantage and Medicaid are outside this row

STEP BY STEP

Read date: 10-09-2026

Confirm that the plan includes an out-of-network benefit. The Oxford form is expressly for out-of-network claims, but some products do not cover routine out-of-network care. Oxford Medical Claim Form
Complete Oxford Medical Claim Form 19-11958 12049 R2. Complete every applicable field and all Provider Information fields. A provider may complete the Provider Information section. Oxford Medical Claim Form
Attach a Superbill or Invoice with patient name, dates of service, ICD-10 diagnosis codes, CPT or HCPC procedure codes and modifiers, units, billed amount per procedure, and place of service. Attach payment receipts and a primary-plan EOB when applicable. Oxford Medical Claim Form
Leave the Assignment of Benefits box unchecked to keep payment with the member. Check it only to request payment directly to the provider. Sign and date the form. Oxford Medical Claim Form
Portal upload NO. The public form directs only an offline route. Destination details are excluded. myuhc.com and the UnitedHealthcare app are published for EOBs and claim viewing, not Oxford member claim upload. Oxford Medical Claim Form UnitedHealthcare claims
NOT PUBLISHED: the generic claim deadline and Oxford-specific processing time. The controlling certificate of coverage or summary plan description governs. Review the EOB at myuhc.com after processing. Oxford Medical Claim Form

Portal upload: NO
Portal: myuhc.com and UnitedHealthcare app
Portal path: NOT APPLICABLE: Oxford form directs the completed claim and attachments to an offline route
Mail address: PLAN-DEPENDENT: Mail it to the address listed on the back of your health plan ID card.
Fax: NOT PUBLISHED
Attach: Patient name; dates of service; ICD-10 diagnosis codes; CPT or HCPC procedure codes with modifiers; units; billed amount for each procedure; place of service; provider name; provider address; service address; NPI; Tax ID; group or facility name
File types: NOT APPLICABLE
File size limit: NOT APPLICABLE
Maximum files: NOT APPLICABLE
One file or separate files: NOT APPLICABLE
Confirmation: EOB after processing
Status check: myuhc.com EOB and claim view; UnitedHealthcare app shows claims
Processing time: NOT PUBLISHED: UnitedHealthcare says many claims process within 14 business days but does not identify an Oxford-specific time
Member deadline: NOT PUBLISHED: controlling COC or SPD determines the claim deadline
Deadline basis: New Jersey, Connecticut, and ASO plan terms can differ
Mental health route: Use the mental health number on the member ID card for plan-specific behavioral benefits; no different public self-file form or portal is published

Confirm the address, fax number or portal path on the insurer's own claims page before you send; read on 10-09-2026.

Read on 10-09-2026 from https://uhc-gpd-green.uhc.com/content/dam/uhcdotcom/en/IndividualAndFamilies/PDF/Ox-NJ-CT-ASO-Medical-Claim-Form.pdf. Confirm the address, fax number or portal path on the insurer's own claims page before you send.