Worldwide Toll-Free Numbers

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1 Worldwide Toll-Free Numbers Use the following toll-free access numbers to reach HCC Medical Insurance Services from outside of the United States: Country Access Number Country Access Number Argentina Italy (Milan Economy) Australia Italy (Rome Economy) Australia (Adelaide Economy) Italy - Italiano Australia (Brisbane Economy) Japan Australia (Melbourne Economy) Lithuania Australia (Perth Economy) Luxembourg Australia (Sydney Economy) Macau Austria Malaysia » Austria (Vienna Economy) Mexico Bahamas Grand Bahamas, Mexico (Guadalajara Economy) Nassau, Paradise Island Belgium Mexico (Mexico City Economy) Belgium (Brussels Economy) Mexico (Monterrey Economy) Belgium (Nationwide Economy) Mexico (Nationwide Economy) Brazil Netherlands Canada Netherlands (Amsterdam Economy) Canada (Montreal Economy) Netherlands (Rotterdam Economy) Canada (Toronto Economy) New Zealand » Chile » New Zealand (Auckland Economy) China (North) » Nicaragua China (South) » Norway (Oslo Economy) Colombia Panama Croatia Peru Cyprus Poland Denmark » Portugal Denmark (Nationwide Economy) Puerto Rico Dominican Republic » Russia » Finland » Singapore Finland (Helsinki Economy) South Africa France South Korea France (Lille Economy) Spain France (Lyon Economy) Spain (Barcelona Economy) France (Marseille Economy) Spain (Hotel) France (Nantes Economy) Spain (Madrid Economy) France (Nationwide Economy) » Spain (Nationwide Economy) France (Nice Economy) Spain Español France (Paris Economy) St Vincent & the Grenadines France (Toulouse Economy) Sweden France Français Sweden (Norrkoping Economy) Germany Sweden (Stockholm Economy) Germany (Berlin Economy) Switzerland » Germany (Frankfurt Economy) Switzerland (Nationwide Economy) Germany (Munich Economy) Switzerland (Zurich Economy) P age ( 1 of 2)

2 Germany Deutsch Thailand » Greece Spain Hong Kong » Trinidad and Tobago Hong Kong (Economy) United Arab Emirates Hungary United Kingdom Iceland » UK (Bath Economy) India » UK (Cambridge Economy) Indonesia » UK (Edinburgh Economy) Ireland UK (London Economy) Ireland (Dublin Economy) UK (Nationwide Economy) Ireland (Nationwide Economy) UK (Oxford Economy) Israel » United States (48 States) Italy Venezuela Unavailable from mobile phones in some cases. Last updated 01/23/14» Unavailable from payphones in some cases. To place a call to one of our World Service Center representatives: 1. Dial the toll-free access number for the country in which you are traveling. Important Note: Use the economy number, where available, for cheaper calls. 2. Dial # when asked for your account code. 3. You will be immediately connected to a World Service Center representative at HCCMIS. If you experience difficulty using any of the country access numbers listed above, call us collect from anywhere in the world at (Be sure to mention the appropriate country code (1) and area code when calling). P age ( 2 of 2)

3 Fellow Safety Committee: Fellow Health Insurance Steps for Fellows Who Need Medical Attention Contact Information: HCC Medical Insurance Services P.O. Box 863 Indianapolis, Indiana Phone Number 1 : (317) Description of Coverage: The Description of Coverage sent out to all Fellows enrolled in HCC contains the plan benefits, and detailed list of policies. Review it carefully to ensure that you have sufficient coverage to meet your medical needs. Important Information to Note: Page 4-11 Eligible Expenses/Coverage Page Definitions Steps to take when a Fellow needs medical attention: Have an emergency Seek medical attention first and foremost Contact HCC and start a case file o Make sure you obtain contact information for the doctor or medical professionals who treat you; if they do not have a business card with contact information, get phone number Complete Claimant Statement form (send forms with receipts and diagnosis forms to Indianapolis) FOLLOW UP Nonemergency visit Call HCC to inquire and confirm the documents and paperwork needed in order to get reimbursed and approved for coverage 2 Seek medical attention Contact HCC and start a case file o Make sure you obtain contact information for the doctor or medical professionals who treat you; if they do not have a business card with contact information, get phone number 1 Number to call when Fellow outside of the United States 2 Optional step but highly recommended so Fellow can minimize possibility of complications when working with HCC

4 Complete Claimant Statement form (send forms with receipts and diagnosis forms to Indianapolis) FOLLOW UP Possible difficulties when engaging with HCC: Representative may want to talk directly with doctor who treated you but, hospital visit may be informal where this is not possible (may be hard to communicate with insurance company and attending doctor) o Unless representative is able to speak directly with doctor, insurance company may not reimburse Fellow Doctor may not have file on for you and your treatment Fellows should submit the claimant's statement and billing receipts to HCC. Once the claims are reviewed and processed, HCC would send out an EOB (Explanation of Benefits) statement. You may have to advocate for your healthcare; necessity is a relative term to those who are not needing medical attention i.e. HCC representatives Must obtain itemized bill (list of treatment and medication); not a general invoice Claims Procedure 1. Fill in and sign the completed Claimant s Statement and Authorization form (Attachments) 2. If the claim you submit is a result of an accident, fill in the Accident Questionnaire (Attachments) 3. Attach all original itemized bills for services and supplies. Please verify that the documents indicate your name, date of service, diagnosis and the charge for each service. 4. Mail to: HCC Medical Insurance Services, LLC P.O. Box 863 Indianapolis, Indiana It usually takes up to 30 days to process any claims. To save time, you can the images to HCC will review and approve all bills before payment is made. An EOB (Explanation of Benefits) letter will be sent on every submission letting Members know if it is an approved expense. If not, they will also let them know why. 6. If you have any questions, call And if you encounter any problems while using this number, you may reach our point of contact for Case Management, Vania Milheirao at ext 1502 or

5 Frequently Asked Questions: HCCMIS Claims (Source: 1. Do I need to pre-certify HCCMIS for a doctor visit? HCCMIS does not require pre-certification for simple doctor visits. Contact HCCMIS in advance or within 48 hours for the following: * Transplants * Inpatient Care * Surgery or Surgical Procedure * Extended Care Facility * Home Nursing Care * Durable Medical Equipment * Artificial Limbs * CAT scans & MRIs * Maternity Maternities must be pre-notified within the first 90 days of the pregnancy and again within 48 hours following the delivery. Maternity coverage varies by plan. The following items must be pre-notified in advance and coordinated by HCCMIS to be considered for coverage: * Trip Interruptions * Repatriation of Remains * Emergency Medical Evacuation * Emergency Reunion 2. What will happen if I do not pre-certify? Eligible Medical Expenses will be reduced by 50%, the deductible, if applicable, will be subtracted from the remaining eligible amount, and then the Benefit Percentage will be applied. If Pre-certification requirements are not met for transplant treatment, benefits are forfeited for all services or supplies for the Transplant. 3. What happens if I become ill or injured over the weekend and need to contact HCCMIS? Please phone or We accept all collect calls. Our World Service Center representatives are available 24 hours a day, 7 days a week for benefit inquiries, pre-certifications, and general assistance. 4. Once I pre-certify treatment, is coverage guaranteed for that treatment? Pre-certification is not a guarantee of benefits. Although you ve completed the Pre-certification Requirement, all plan provisions and conditions must be met at the time of treatment. We cannot authorize or guarantee any benefit prior to the service.

6 5. Do I have to pay the doctor up front? If the provider requires you to pay up front, you may submit the original itemized bills and paid receipts to us along with a completed Claimant's Statement. 6. How do I get a Claimant's Statement? You may obtain a copy of the Claimant's Statement by visiting or through the "Claim Information" section of Client Zone. If you do not have access to the internet, please feel free to contact our World Service Center so that we may send a form to you by fax or by mail. 7. Do I need to send a completed Claimant s Statement and Authorization with every bill? No, you should submit one Claimant's Statement to HCCMIS for each different condition or diagnosis only. 8. Does my plan cover prescription drugs? Most HCCMIS policies do not have a prescription drug card. Prescriptions should be paid for at the pharmacy then submitted to us as a claim for reimbursement. Please include the prescription label and your paid receipts with a completed Claimant's Statement. 9. Can my doctor call if they have questions about what my plan covers? Yes. We can define the benefits that are available within your coverage; however, we cannot pre-approve any treatment or guarantee payment in advance 10. How long will it take for my claim to be processed? The claims department needs at least business days to set up a file and begin reviewing a submitted claim. If additional information is needed to process the claim, written requests will be sent at that time. After all required information is received and reviewed, the claims will be processed according to the terms of the insurance. 11. How do I find out about status of submitted claims? You are welcome to contact us during regular business hours (8:00am to 6:30pm Eastern Time) to inquire about the status of a claim. 12. Is the Explanation of Benefits a bill? The EOB is not a bill. Rather, it is an explanation of how your claim has been processed. Please click here for more information. 13. What if I do not agree with a claims denial? You may ask for HCCMIS to reconsider the denial by submitting a request for an appeal in writing within 90 days. In order for the claims department to review the appeal, you must supply additional documentation to support a reversal of the denial. For complete benefits, please refer to your plan. You may contact the HCCMIS World Service Center if you need a duplicate copy of your Plan. If you have further questions, please feel free to contact HCCMIS World Service Center at or (collect calls accepted). You are also welcome to contact us by to

7 CLAIMANT S STATEMENT AND AUTHORIZATION (See reverse side for Directions for Submitting a Claim) HCC Medical Insurance Services Box No Farmington Hills, MI PART A: Complete for all claims. **All Checks and Correspondence Will Be Sent To The Address Below** Insured Name: Claimant (Patient) Name: Sex: Birthdate: Sex: Birthdate: Home Telephone: Mailing Address (include Street Address, City, State, Country, and Work Telephone: Postal Code): Fax Number: address: Plan Number: Certificate Number: 1. Citizenship of Claimant: Home Country of Claimant: (Country where you principally reside & receive regular mail) Country Visited: (HCCMIS may request a copy of your passport) 2. Is the Claimant: A full-time Student? Yes No If yes, please provide the name and address of school: 3. Is the Claimant: Employed? Yes No If yes, please provide the name and address of employer: 4. Do you or any family members have other coverage (medical, indemnity or liability) which might help cover hospital and medical expenses? Yes No If yes, please provide the following: Name of Company: Policyholder: Is this group insurance? Yes No Address: Policy Number: PART B: Complete for new claims. If you need additional space, please attach additional sheets. 1. How did the condition begin? State fully all symptoms and describe the condition in detail from the beginning: 2. When did the first symptoms of this condition begin? State the exact date, if possible: (If due to an accident, please complete accident questionnaire, see Part C- DIRECTIONS) 3. Have you ever had or been treated for the same kind of illness or injury? Yes No If Yes, when? Name, address and telephone number of attending physician: 4. Name, address and telephone number of family physician (even if not consulted): 5. What ailments, diseases, illnesses, conditions or injuries have you had during the last five years? Please provide name and/or description of each condition, dates involved, and the name, address and telephone numbers of attending physicians: CSA (CF) 02/13

8 PART C: Complete for all claims. I verify that all information contained in this form is true, correct and complete to the best of my knowledge. I authorize any licensed doctor, practitioner of the healing arts, hospital, clinic, health related facility, pharmacy, government agency, insurance company, group policyholder, employee or benefit plan administrator having information as to the care, advice, treatment, diagnosis or prognosis of any physical or mental condition, or the financial or employment status of the insured named below, to provide this information to HCC Medical Insurance Services. I understand that I have the right to receive a copy of this authorization upon request. A copy of this shall be as valid as the original. This authorization is valid for twelve months from the date signed: Signature of Insured: Print Name: Date: Signature of Patient: Print Name: Date: ASSIGNMENT OF BENEFITS AUTHORIZATION: I authorize payment of medical benefits to the doctor or other supplier of services submitting the attached bills. Signature of Insured: Date: DIRECTIONS FOR SUBMITTING A CLAIM 1. If this is a new claim, complete ALL PARTS of this form. 2. If this claim is a result of an accident, please visit Downloads to obtain the ACCIDENT QUESTIONNAIRE, or contact our office to request the form. 3. If this is a continuing claim, complete Parts A and C only. 4. Attach all original itemized bills for services and supplies. Please verify that the documents indicate your name, date of service, diagnosis and the charge for each service. 5. Mail to: HCC Medical Insurance Services Box No Farmington Hills, MI If you have any questions, call If calling from outside the US, call collect to (317) INDIANA LAW REQUIRES US TO NOTIFY YOU OF THE FOLLOWING: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete or misleading information commits a felony. CSA (CF) 02/13

9 ACCIDENT QUESTIONNAIRE HCC Medical Insurance Services Box No Farmington Hills, MI Please first refer to the Claimant s Statement and Authorization form Part B, Question #2. If your reply is that the cause of a claim is due to an accident, please complete and submit this form to HCC Medical Insurance Services. Insured Name: Certificate Number: Claimant (Patient) Name: Date of Accident/Injury: Citizenship of Patient: Home Country of Claimant: (Country where patient principally resides and receives regular mail) Country Visited: (HCCMIS may request a copy of your passport) 1. Please provide a brief summary of the accident details, including date, time, location, and how the accident occurred: 2. Was the accident related to your employment? Yes No If yes, please provide the name, address and telephone number of employer: 3. Was the accident involving a Motorized Vehicle? Yes No If yes, please provide the following: Name, address, and telephone number of the Company providing insurance of the vehicles involved: 4. In the event that you have hired legal counsel, please advise of your Case Number, and the name, address, and telephone number of your attorney? Signature of Insured: Print Name: Date: Signature of Patient: Print Name: Date: AQ 01/13

10 Member Benefits Overview When seeking medical treatment or services, members are always free to use the medical providers of their choice. While we do not recommend any one provider or facility over another, an in-network PPO provider listing for medical services rendered in the US can be located directly at or by contacting us at or International direct-bill providers can also be searched via A Claimant s Statement & Authorization Form is required for each medically treated condition or service in order to consider any claim submitted. Please complete the entire form and return to HCCMIS as soon as possible to avoid delays in the processing of any claim. The Claimant s Statement & Authorization Form may be downloaded immediately from or you may contact HCCMIS to obtain this form. If you have an injury, please also complete the Accident Questionnaire in addition to the Claimant s Statement. Members are not required to contact the World Service Center (HCCMIS customer service) for simple doctor visits unless you would like to use a directpay provider from our international provider list on to ensure direct-billing is in place, please call prior to your visit to allow us time to contact the provider. Members are required to contact the World Service Center and pre-certify within 48 hours of any hospital admission or any medical emergency. Members are required to contact the World Service Center in advance of occurrence for the following: Transplants, Inpatient Care, Surgery or Surgical Procedure, Extended Care Facility, Home Nursing Care, Durable Medical Equipment, Artificial Limbs, CAT Scans & MRIs, and Maternity. Maternities must be pre-certified within the first 90 days of the pregnancy and again within 48 hours of delivery. Pre-certification is not a guarantee of benefits or a guarantee of payment. If a medical provider is willing to bill HCCMIS directly, we will be more than happy to work directly with the provider. The decision to direct bill medical services to HCCMIS is solely at the discretion of the medical provider. If the provider requires the member to pay up front for medical services, the member should submit to HCCMIS the original itemized bills and paid receipts to us along with the completed Claimant s Statement and Authorization form. This is not an inclusive list of member benefits, services or requirements, nor does it imply any guarantee of coverage or payment. For additional information, please contact the World Service Center. Fax (317) or by Telephone (800) or (317) (collect calls accepted).

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