RE: SUBROGATION/REIMBURSEMENT PROVISION/EXCESS EXCLUSION

Transcription

1 Subrogation Unit P O Box 8073 Wausau, WI ADDRESSEE S NAME TITLE COMPANY NAME STREET ADDRESS CITY STATE ZIP CODE EMPLOYEE: CLAIMANT: EMPLOYER: MEMBER ID: CLAIM CONTROL NO.: DATE OF ACCIDENT: RE: SUBROGATION/REIMBURSEMENT PROVISION/EXCESS EXCLUSION Your claim has been denied because we need additional accident information. Refer to your Plan s Claims and Appeals Procedures. To complete your claim you may provide the details of the accident by visiting or by completing this questionnaire and returning it to UMR in the enclosed envelope. You may call (866) to provide additional information if this is not accident related. 1. Is the treatment the result of an injury or accident? Yes ( ) No ( ) 2. Is the accident or illness the result of a work-related injury? Yes ( ) No ( ) 3. Is the accident or illness result of self-employment? Yes ( ) No ( ) If you answered No to the above questions, please sign where indicated and return the letter in the envelope provided. If you answered Yes to any of the questions, answer all questions below: 4. Date of accident or injury: Time: Happened: Home ( ) Auto ( ) Work ( ) Other ( ) City/State: 5. If this is a motor accident, please include name, address, and phone number of your auto insurance agent: Agent Name: Auto Insurance Company: City/State/Zip: Phone: ( ) ext (T) (F) subrogation@wbi.fiserv.com

2 Page 2 6. Please supply details of the accident: 7. Is this claim the result of an injury or accident, which may be the result of another party s negligence? Yes ( ) No ( ) If Yes, please give the name and address of the responsible third party AND the name and address of the responsible party s insurance carrier: Responsible Party: City/State/Zip: Insurance Company: City/State/Zip: Phone: ( ) - Claim Number: Adjuster: 8. Have you received any payment for this accident or illness? Yes ( ) No ( ) If Yes, please explain amount paid and reason: 9. Have you obtained an attorney? Yes ( ) No ( ) If Yes, give the name, address and phone number of your attorney: Name: City/State/Zip: Phone: ( ) If the injury involved any motor vehicle, or a two, three or four wheeled motorized vehicle, answer the following: A. Was the patient or any occupant under the influence of alcohol or drugs?yes ( ) No ( ) B. Were the patient and all occupants wearing seat belts? Yes ( ) No ( ) C. If the injury involved any two, three or four wheeled motorized vehicle accidents, were the patient and all riders wearing protective headgear?yes ( ) No ( ) I HEREBY CERTIFY THE INFORMATION ON THIS FORM IS TRUE AND ACCURATE. I AUTOHRIZE YOU TO OBTAIN ANY RELEASE AGREEMENT RELATED TO THIS ACCIDENT. Signature: Date: May we have your daytime telephone number in case additional information is required? ( ) -

3 Page 3 Thank you for your assistance. If you have any questions, please call the Subrogation Unit. Sincerely, Subrogation Unit Extension Your group health plan has a Reimbursement Provision. The provision allows us to recover payments from ANY settlement due you when the accident or illness is a result of negligence or work related injury or illness. Subrogation requires that you, as an enrollee of the plan, protect the plan s subrogation right and that you do nothing to prejudice this right. Also, the plan contains an EXCESS EXCLUSION. This means that if non-health insurance (such as Automobile, Homeowners, or other similar insurance) includes a medical expense benefit, that benefit would need to be exhausted before charges can be considered for payment under the health. To avoid delays, please submit this bill and any other bills to the liability carrier for consideration. If the other carrier does not pay or payment is not made in full, copies of any written correspondence from the carrier should be sent to us. If the correspondence is not received within 60 days, we will assume the other insurance paid the charges.

4 Page 4 SUBROGATION AGREEMENT Employer: Employee: Claimant: Certificate #: Date of Injury: In accordance with the provision of this group health plan, I agree that if payment should be received from any other person or organization responsible for injuries sustained, whether by legal action settlement or otherwise, I will reimburse the Plan to the extent of benefits provided, immediately upon collect of damages. I also authorize and direct reimbursement to UMR, formerly FISERV HEALTH of the amounts otherwise payable to me or on my behalf to others, but not to exceed the benefits paid under this Group Health Plan, as a result of the injuries sustained. Participant s Signature Date Employee s Signature Date PLEASE SIGN AND RETURN THIS FORM IMMEDIATELY IN THE ENCLOSED ENVELOPE. FAILURE OR REFUSAL TO EXECUTE THIS DOCUMENT RELIEVES THE PLAN OF ANY AND ALL LEGAL, FINANCIAL OR CONTRACTUAL OBLIGATION FOR ANY EXPENSES INCURRED BY THE PARTICIPANT.

5 Team Member Questionnaire Employer: The Venetian The Palazzo Sands Casino Resort Bethlehem Group Number: Welcome to UMR! In order to process your claims, we must collect the following information from you for all covered dependents and Medicare eligible Team Members or dependents. Failure to complete and return this form may delay payment of your claim(s). A. OTHER INSURANCE: Please call or go online to member-fhs.umr.com to update this information or complete the following and return this form to UMR at the address provided below. If you and/or your dependent(s) have medical coverage with UMR AND have medical insurance coverage with another company, please complete the following sections OR provide a copy of the other insurance ID card, front and back. If you and/or your dependent(s) do not have medical insurance coverage with another company, please check the box below this section. Name and date of birth of primary card holder Other insurance name Other insurance ID number Other insurance phone number Dependent Name (First & Last Name) Dependent Date of Birth Social Security Number Relationship to Team Member Covered by Other Insurance? Y / N Effective Date Check here if you or your dependents have no other group health or Medicare coverage. B. DEPENDENT STATUS: Please complete the information below for any covered dependent age 19 and over. Check your employee Summary Plan Description regarding eligible dependents. ( Percent of Support is the portion of financial support you provide this dependent. Handicapped refers to dependents who are incapacitated or so severely disabled that they are unable to perform gainful work.) If your dependent is a full-time student, please attach verification of full-time student status. A signed document on school letterhead from the school registrar identifying the dependent as Full Time is required. (Preregistration is not acceptable proof). Also please complete the information below. Dependent Name Handicapped? School Name Graduation Date Credits this Semester Percent of Support I hereby certify that all information given here by me is accurate and true. Print Team Member Name Team Member Signature Date Team Member s Phone Number: Team Member s ID Number:

6 Team Member Questionnaire Employer: The Venetian The Palazzo Sands Casino Resort Bethlehem Group Number: Please return to: UMR PO Box 8077 Wausau, WI Effective Date: Thank you for your assistance!