Dominican University of California Office of Athletic Training Athletic Insurance Policies and Procedures

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1 Athletic Insurance Policies and Procedures 1. Insurance: a. Personal Insurance: Primary coverage. i. All Dominican university student athletes are required to have a full coverage medical insurance policy prior to participation in athletic activities (primary insurance). ii. The primary insurance policy must be active prior to participation in athletics. iii. Proof of primary insurance coverage must be on file with the sports medicine/athletic training office iv. If primary insurance is an HMO (HealthNet, Blue Shield, etc...) or has an in-network provider, call and request away from home coverage and join Meritage Medical Network and if possible select Dr. David Goltz Orthopedic Surgeon as doctor of choice to allow for doctors visits without having to travel home for care. If you live in the Bay Area and would like to stay in that network that is acceptable but could require travel to the in-network provider. v. If you have Kaiser and reside outside of Northern California call and request a Northern California Kaiser number to allow for quicker services while at school. vi. A copy of an insurance card evidencing current primary insurance coverage must be on file with the sports medicine/athletic training office vii. Proof of insurance on file with admissions will not be accepted as proof of primary insurance for athletic participation. b. Dominican University Provided Insurance: Secondary coverage. i. Dominican University provides secondary insurance through an independent carrier that is active throughout the academic school year. ii. All student athletes are covered by this secondary insurance without cost to the athlete or parents. iii. Secondary insurance is a supplement only to primary insurance coverage. iv. Dominican university provided secondary insurance is not a comprehensive major medical policy, as set forth below. v. All student athletes are covered by a separate insurance policy for catastrophic injury. This policy is provided by Dominican university according to NAIA guidelines/requirements through an independent carrier. Coverage is for accidental death and disability 2. Insurance Benefits: Secondary coverage. a. Accident/Injury benefits for athletes are on an excess only basis. b. Athlete s own primary insurance must be billed prior to requesting secondary insurance coverage for any unpaid medical expenses that are covered by the terms and conditions of the secondary coverage

2 c. Benefits available through secondary coverage apply only after payment/non-payment by the primary insurance carrier. d. Expenses that are covered in accordance with section 4 below which are not covered by primary insurance carrier will be payable through the secondary insurance carrier. e. Dominican university shall have no responsibility to cover medical expenses that are not covered by primary and/or secondary insurance. f. All remaining expenses, or those expenses not covered by the primary and secondary insurance carriers are the responsibility of the athlete/parents. 3. Termination of benefits: Secondary coverage. a. Athletic insurance benefits from secondary coverage expire 2 years from the date of the original injury, irrespective of the date upon which the injury is reported. b. Failure to report an injury or file a claim within the 2 year benefits period will result in no secondary insurance coverage for medical expenses incurred by the student athlete. c. To the extent that the provisions of the secondary insurance policy provide benefits that differ from what is stated in these policies and procedures, the provisions of the secondary insurance policy shall prevail; provided that this shall not result in any direct responsibility for payments by Dominican university 4. Specific policies and procedures a. Dominican university provided secondary insurance is not a comprehensive/major medical insurance policy. Illness/disease is not covered by the secondary insurance policy. b. All required co-pays for medical services or office visits that fall within the coverage of the secondary insurance are eligible to be paid by the secondary insurance. c. Amounts that apply to deductibles required by the primary insurance carrier for medical services that are covered by secondary insurance will be eligible for reimbursement under the secondary insurance coverage. d. Secondary insurance does not cover complications that result from or are due to injuries/conditions that are pre-existing. e. Secondary insurance coverage does not apply to non-accidental injury, or nonathletic related injury. f. Secondary insurance coverage applies to accidental injury that is a result of participation in university sanctioned athletics. i. Accidental injury is any injury that results from a sudden unexpected traumatic event. A. Covered examples: a. Twisted knee resulting in torn ligaments/cartilage b. Acute muscle strain/rupture from throwing or running type motion. c. Fractures/Contusions resulting from collision with another player, Ground contact etc.

3 B. Non-covered examples: a. Subluxing joint due to inherent laxity. b. Chondromalacia, Osteoarthritis secondary to previous injury or predisposition. g. All covered accidental injuries are those that occur during scheduled practice, game, or conditioning activity that is sanctioned by the athletic department. h. Active participation in athletics applies to all individuals included on a team s roster, coaching staff or those individuals attempting to become a member of the team s roster. i. Only those athletes enrolled in classes at Dominican university are covered for accidental injury. All others must submit proof of insurance prior to participation in any university sanctioned athletics (i.e. team tryouts, team scrimmage). j. Injury that occurs during the performance of recreational, personal, or physical education/intramural activities are not covered by secondary insurance. 5. Procedures a. All injuries must be reported to the sports medicine/athletic training office within 24 hours. There are no exceptions. b. All non-emergency injuries sustained during active participation in athletics must be referred through the sports medicine /athletic training office. There are no exceptions. c. Athletes are referred for medical care on a needs basis. Any athlete may request consultation with the team physician through the sports medicine/athletic training office anytime. d. All consultations for second opinions require notification to the team physician and the sports medicine/athletic training office prior to obtaining said appointment. e. Any athlete that self refers, or visits a medical care provider without referral including second opinions will be responsible for all medical costs incurred. f. All injuries must be verified as to time, place, and cause before a claim will be considered valid. g. All primary medical care must be received within 30 days of injury. h. An injury report signed by the head athletic trainer must be completed prior to a physician visit or a claim being filed for medical expenses. i. The Dominican university team physicians should be used at all times if possible for accidental injury of a non-urgent nature. j. The Dominican university student health center and/or the team physicians are available for non-accidental injury or illness. These services should be utilized whenever possible. k. The student athlete/spouse or parent is responsible for verification of coverage prior to obtaining a visit with a health care provider. l. All pre-authorization requirements according to primary insurance carrier policy for medical care are the responsibility of the athlete/spouse or parents.

4 m. The athlete/spouse or parents are responsible for ensuring that all appropriate claim forms are filed with the primary insurance carrier. n. The athlete/spouse or parents are responsible for ensuring that all medical bills for services rendered are forwarded to the primary insurance carrier. o. An additional copy of all medical bills must be submitted to the sports medicine/athletic training office. p. Failure to follow the guidelines/procedures included in this document or those procedures/guidelines stipulated in the primary or secondary insurance carriers policy may jepordize payment for any and all medical services rendered for an injury sustained during athletic participation. q. The following items are required to complete a claim through Dominican university secondary insurance carrier: i. A completed and signed injury report. ii. An itemized bill from all medical providers. iii. An explanation of benefits (EOB) from primary insurance carrier. iv. A completed and signed secondary insurance claim form. r. No claim for payment through Dominican university secondary insurance carrier will be accepted without all items mentioned above.

5 FORM 1 Dominican University of California Acknowledgement of Insurance Policies and Procedures All athletes receiving medical care from a physician are required to have written clearance from the attending/treating physician and the head athletic trainer before returning to practice/play. All athletes treated through the sports medicine/athletic training office or student health center are required to have written approval from the head athletic trainer and health center director prior to returning to practice/play. There will be no exceptions to any of the previously stated procedures. If primary insurance is an HMO (HealthNet, Blue Shield, etc...) or has an in-network provider, call and request away from home coverage and join Meritage Medical Network and if possible select Dr. David Goltz Orthopedic Surgeon as doctor of choice to allow for doctors visits without having to travel home for care. If you live in the Bay Area and would like to stay in that network that is acceptable but could require travel to the in-network provider. By signing below the student athlete/spouse and or parent/guardian acknowledges receipt and understanding of all Dominican university athletic insurance policies and procedures. Athlete signature Print Name Parent/Guardian (Applies to all athletes) Original copy of this page must be on file with the Dominican University Department of Athletics prior to participation in any Dominican university sanctioned athletics, including preseason training

6 FORM 2 Insurance Information The following information is required of all athletes to assure that medical expenses are adequately and/or completely covered by an insurance policy. Inadequate or incomplete information may delay insurance payments or void coverage for medical expenses. It is the sole responsibility of the athlete to ensure that all information is correct and current prior to participation in Dominican university athletics. No claim for medical expenses will be filed through Dominican university secondary insurance carrier without this information. Name: D.O.B. Sex: Campus Address: City: Home Address: City: State: Zip code: Phone : Cell Phone: Mother s Name: Address: Father s Name: Address: City: State: City: State: Phone: Phone: Dominican University Insurance Plan: Y N (circle one) Insurance Carrier: Plan Type: POS PPO HMO (circle one) Group Policy No.: I.D. #: Phone: Pre-Authorization required: Y N (circle one) Address: City: State: Zip code:

7 Emergency Contact Information Name: Relationship: Phone: Cell Phone: Address: City: State: I/We the undersigned certify that the foregoing is true and correct to the best of our knowledge. I/We authorize Dominican university sports medicine to contact the aforementioned insurance carrier to verify type of plan and coverage. Signed: : Signed: : Print Name: (athlete) Print Name: (parent/guardian/spouse)

8 Dominican University Athletic insurance Policies and Procedures 6. Insurance: a. Personal Insurance: Primary coverage. i. All Dominican University student athletes are required to have a full coverage medical insurance policy prior to participation in athletic activities (primary insurance). ii. Primary insurance policy must be active prior to participation in athletics. iii. Proof of insurance coverage must be on file with the sports medicine department. iv. Copy of insurance card must be on file with the sports medicine department. v. If primary insurance is an HMO (HealthNet, Blue Shield, etc...) or has an in-network provider, call and request away from home coverage and join Meritage Medical Network and if possible select Dr. David Goltz Orthopedic Surgeon as doctor of choice to allow for doctors visits without having to travel home for care. If you live in the Bay Area and would like to stay in that network that is acceptable but could require travel to the in-network provider. vi. If you have Kaiser and reside outside of Northern California call and request a Northern California Kaiser number to allow for quicker services while at school. vii. Proof of insurance on file with admissions will not be accepted as proof of insurance for athletic participation. b. Dominican University Insurance: Secondary coverage. i. Dominican University secondary insurance is active throughout the academic school year. ii. All student athletes are covered by secondary insurance without cost to the athlete or parents. iii. Secondary insurance is a supplement only to primary insurance coverage. iv. Dominican university secondary insurance is not a comprehensive major medical policy. v. All student athletes are covered by a separate Dominican university insurance policy for catastrophic injury. 7. Insurance Benefits: Secondary coverage. a. Accident/Injury benefits for athletes are on an excess only basis. b. Athlete s own insurance must be billed prior to requesting secondary insurance coverage for any unpaid medical expenses. c. Benefits through Dominican universities secondary coverage apply only after payment/non-payment by primary insurance carrier.

9 d. Expenses not covered by primary insurance carrier will be payable through Dominican universities secondary insurance carrier. e. At no time will university funds outside of insurance premiums be utilized to cover medical expenses. f. All remaining expenses, or those expenses not covered by either insurance carrier are the responsibility of the athlete/parents. 8. Termination of benefits: Secondary coverage. a. Athletic insurance benefits from secondary coverage expire 2 years from date of original injury. b. No insurance benefits/coverage is implied/expressed or guaranteed 2 years after an injury is sustained. c. Failure to report an injury or file a claim within the 2 year period will result in no university insurance coverage for medical expenses incurred by the student athlete. 9. Specific policies and procedures a. Dominican university secondary insurance is not a comprehensive/major medical insurance policy. Illness/disease is not covered by the university s secondary insurance policy. b. All required co-pays for medical services or office visits are covered by Dominican university secondary insurance. c. All amounts that apply to deductibles required by primary insurance carrier are covered by Dominican university secondary insurance. d. Dominican university secondary insurance does not cover complications that result from or are due to injuries/conditions that are pre-existing. e. Dominican university secondary insurance coverage does not apply to nonaccidental injury, or non-athletic related injury. f. Dominican university secondary insurance coverage applies to accidental injury that is a result of participation in university sanctioned athletics. i. Accidental injury is any injury that results from a sudden unexpected traumatic event. A. Covered examples: a. Twisted knee resulting in torn ligaments/cartilage b. Acute muscle strain/rupture from throwing or running type motion. c. Fractures/Contusions resulting from collision with another player, Ground contact etc. B. Non-covered examples: a. Subluxing joint due to inherent laxity. b. Chondromalacia, Osteoarthritis secondary to previous injury or predisposition.

10 g. All accidental injuries are those that occur during scheduled practice, game, or conditioning activity that is sanctioned by the athletic department. h. Active participation in athletics applies to all individuals included on a team s roster, coaching staff or those individuals attempting to become a member of the team s roster. i. Only those athletes enrolled in classes at Dominican university are covered for accidental injury. All others must submit proof of insurance prior to participation in any university sanctioned athletics (i.e. team tryouts, team scrimmage). j. Injury that occurs during the performance of recreational, personal, or physical education/intramural activities are not covered by Dominican university secondary insurance. 10. Procedures a. All injuries must be reported to the sports medicine/athletic training department within 24 hours. There are no exceptions. b. All non-emergency injuries sustained during active participation in athletics must be referred through the sports medicine department/athletic training room. There are no exceptions. c. Athletes are referred for medical care on a needs basis. Any athlete may request consultation with the team physician through the sports medicine department at anytime. d. All consultations for second opinions require notification to the team physician and the sports medicine/athletic training department prior to obtaining said appointment. e. Any athlete that self refers, or visits a medical care provider without referral including second opinions will be responsible for all medical costs incurred. f. All injuries must be verified as to time, place, and cause before a claim will be considered valid. g. All primary medical care must be received within 30 days of injury. h. An injury report signed by the head athletic trainer must be completed prior to a physician visit or a claim being filed for medical expenses. i. The Dominican university team physicians should be used at all times if possible for accidental injury of a non-urgent nature. j. The Dominican university student health center and/or the team physicians are available for non-accidental injury or illness. These services should be utilized whenever possible. k. The student athlete/spouse or parent is responsible for verification of coverage prior to obtaining a visit with a health care provider. l. All pre-authorization requirements according to primary insurance carrier policy for medical care are the responsibility of the athlete/spouse or parents. m. The athlete/spouse or parents are responsible for ensuring that all appropriate claim forms are filed with the primary insurance carrier. n. The athlete/spouse or parents are responsible for ensuring that all medical bills for services rendered are forwarded to the primary insurance carrier. o. An additional copy of all medical bills must be submitted to the sports medicine/athletic training department.

11 p. All student athletes that have a Health Maintenance Organization (HMO) as their primary insurance carrier must use the appropriate HMO medical facilities for non-urgent and urgent care if possible. q. Any athlete whose primary insurance does not pay full coverage or who has a required deductible will be covered for said expenses through Dominican university secondary insurance. r. The following items are required to complete a claim through Dominican university secondary insurance: i. A completed and signed injury report. ii. An itemized bill from all medical providers. iii. An explanation of benefits (EOB) from primary insurance carrier. iv. A completed and signed secondary insurance claim form. s. No claim for payment through Dominican university secondary insurance will be accepted without all items mentioned above. All athletes receiving medical care from a physician are required to have written clearance from the attending/treating physician and the head athletic trainer before returning to practice/play. All athletes treated through the sports medicine department/student health center are required to have written approval from the head athletic trainer/health center director prior to returning to practice/play. There will be no exceptions to any of the previously stated procedures. If primary insurance is an HMO (HealthNet, Blue Shield, etc...) or has an in-network provider, call and request away from home coverage and join Meritage Medical Network and if possible select Dr. David Goltz Orthopedic Surgeon as doctor of choice to allow for doctors visits without having to travel home for care. If you live in the Bay Area and would like to stay in that network that is acceptable but could require travel to the in-network provider. By signing below the student athlete/spouse and or parent/guardian acknowledges receipt and understanding of all Dominican university insurance policies and procedures. Athlete signature Print Name Parent/Guardian (applies to all athletes)

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