Northern Arizona University Athletic Training Insurance Requirements and Policies

Transcription

1 Physician and Billing Procedures: Northern Arizona University Athletic Training Insurance Requirements and Policies Student athletes who sustain injuries while participating in an organized team practice and/or competition have the right to see a physician of their choice and/or our team physicians. All billing is subjective to insurance provider and policy coverage/deductibles. Prior to seeing a non-team physician, consultation with the Head Team Physician and Head Athletic Trainer must occur, per NAU policy. Before returning to team activity, the following must be provided prior to clearance of participation: - dictations from office visit of attending physician - dictations from pre and post-operative procedures/visits of attending physician - restrictions of limitation - clearance to participate - rehabilitation protocol - copies of any diagnostic testing This information allows the medical staff at NAU to adhere to attending physicians orders, maintains an open communication line with outside physician, and ensures quality of care of the athlete. Student athletes will only be covered by Northern Arizona University s secondary insurance for injuries that occur while participating in organized team activities (camps are not considered team activities). Medical expenses for any pre-existing injuries / conditions or illness are the sole responsibility of the student athlete for their duration at NAU. If it is determined that the student athlete did not disclose a pre-existing injury or condition during their physical, any injury associated with that pre-existing injury or condition will not be covered by the secondary insurance. Northern Arizona Universities secondary insurance includes a $1, deductible per injury. The student athlete, their family, and/or their insurance provider are responsible to pay the first $1, before submission of claims can be made. If the incurred medical expense is less than $ , the total of the bill is the responsibility of the student athlete. As stated above, any pre-existing injuries / conditions or illness is the sole responsibility of the student athlete, for their duration at NAU. International Student Athletes: International student athletes are required to carry personal health insurance by the State of Arizona and NAU. The following is a list of their requirements: 1) insurance provide $50,000 per accident or illness, 2) The insurance must cover hospitalization or inpatient care, outpatient care, doctor visits, and outpatient surgery, 3) insurance provides $7,500 for repatriation of remains, 4) insurance provide $10,000 for medical evacuation to home country, and 5) The deductible cannot exceed $100 per accident or illness. Along with these requirements, NAU athletics requires that the policy provides coverage for intercollegiate athletics. As an international student-athlete, you may purchase your health insurance prior to attending NAU or complete the application process for insurance through one of our recommended vendors. If you purchase the insurance on your own, verification by the Medical Service Coordinator will be required. If the policy does not meet the State of Arizona s requirements and NAU athletics, you will not be allowed to participate in any team associated activity. International student-athletes are subject to the same requirement as US citizen athletes as it pertains to current and in good standing health insurance for the entirety of the academic year. Any lapses in payments or temporary cancellations of coverage will affect your eligibility to compete and may limit your health coverage when another policy is purchased. Insurance Coverage:

2 It is strongly recommended that the primary health insurance provides in-network coverage in Coconino County and includes the following minimal coverage: 1) Coverage of all athletic injuries. 2) Coverage of all body parts (no exclusions), 3) Not more than a $500 deductible, 4) 80% pay after deductible for major medical costs 5) $100, minimum for major medical coverage. Northern Arizona University will not be responsible for injuries excluded by your primary health insurance policy. Policies and/or providers that are unfamiliar to the Medical Services Coordinator/Athletic Training Department or obtained through the internet are subject for review. While under review, the student-athlete will be required to provide a letter from the insurance provider stating that they are covered under the policy and that the policy is compliant with NAU athletics insurance requirements. During the review period, the student-athlete will not be allowed to participate in any team associated activity. We strongly encourage the policy holder to verify, with their insurance provider, that there is available coverage in Coconino County. The policy holder needs to be aware of costs associated with in-network and out-of-network providers, physicians associated with their policy, and the potential for additional costs associated with referrals. It is not the responsibility of the Medical Service Coordinator to obtain pre-authorization of services prior to referrals or appointments. It is the responsibility of the policy holder to ensure that the student-athlete has the ability to obtain medical services in Coconino County and by signing the required proof of insurance documents; they understand the policies of NAU athletics and are responsible for any costs that fall outside of that policy. It is the sole responsibility of the student-athlete and the policy holder to ensure and maintain current health insurance coverage. If a policy is cancelled or lapses, it is the responsibility of the student-athlete and/or policy holder to notify the Medical Services Coordinator. If an injury occurs during a policy cancellation or lapse, NAU athletics and their secondary insurance is not responsible for any medical costs associated with that injury (per NAU policy). Once the Medical Insurance Coordinator or athletic trainer is made aware of a policy cancellation or lapse, the student-athlete will be removed from any team associated activity, including team travel.

3 NORTHERN ARIZONA UNIVERSITY ATHLETIC DEPARTMENT PRIMARY HEALTH INSURANCE INFORMATION (Please type or clearly print all information) (The policyholder must sign both sides of this form.) Student Athlete Soc.Sec.Number Birthdate Sport(s) Year of eligibility (Fr, So, Jr, Sr) This policy should meet the recommended minimum requirements in Section A - Health Insurance Requirements - outlined on the opposite side of this page. Any changes in the insurance coverage must be reported immediately. Policyholders' Mailing Address City, State, Zip Policyholders' Phone Number (home) (work) Policyholders' Employer Policyholders' Employers Mailing Address Is your policy an HMO, PPO, or Managed Care Plan? No ( ) Yes ( ) Primary Care Physician Phone number Except for emergency situations, are you required to get a referral to see any health care provider other than your Primary Care Physician or Insurance Company Clinic? No( ) Yes ( ) If your Primary Care Physician or Insurance Company Clinic is not located in the Flagstaff area, are there any participating physicians, clinics, or medical facilities in the Flagstaff area? No ( ) Yes ( ) Flagstaff area Provider Phone Number Will a change in the athlete s enrollment status (full -time student to part-time student) change the athlete s insurance coverage? No ( ) Yes ( ) Is the student athlete covered by another health insurance policy? No ( ) Yes ( ) If yes, please provide the same information for the second policy as asked above. ******************************************************************************************************************* I agree that the information provided is accurate and complete to the best of my knowledge. I agree to notify the Northern Arizona University Athletic Training Department of any changes in insurance coverage. I/We grant permission for medical personnel to provide treatment in emergency situations. (Signature of Policyholder) (The policyholder must sign both sides of this form) (Signature of Guardian if different than Policyholder and student athlete is under 18 years of age) (must sign both sides of form) (Signature of Student Athlete) (The athlete must sign both sides of this form) This completed form must be approved by the Medical Services Coordinator/Athletic Training Department prior to participation in any manner. Any changes in insurance coverage must be reported immediately. Failure to report changes immediately may limit coverage by the secondary insurance. Due dates fall sports (Football, Soccer, Volleyball, X-C) Friday July 15th, ALL other sports Friday August 1st. NORTHERN ARIZONA UNIVERSITY

4 ATHLETIC INSURANCE PARTICIPATION POLICY ******************************** Section A - Health Insurance Requirements ******************************** All athletes must have a primary insurance to participate in any tryout, conditioning workout, practice, or competition. All student athletes participating in Northern Arizona University intercollegiate sports programs are required to have a primary medical insurance that will cover any injuries they may receive. It is strongly recommended that the primary health insurance provides in-network coverage in Coconino County and includes the following minimal coverage: 1) Coverage of all athletic injuries. 2) Coverage of all body parts (no exclusions). (Northern Arizona University will not be responsible for injuries excluded by your primary health insurance policy.) 3) Not more than a $500 deductible. 4) 80% pay after deductible for major medical costs. 5) $100, minimum for major medical coverage. Any changes to the primary health insurance coverage must be reported immediately and a new insurance information form completed including new copies of your insurance cards. ************************ Section B- Northern Arizona University Secondary Athletic Insurance ************************* Northern Arizona Universities Athletic Insurance is a secondary policy only. All athletes must have a primary insurance to participate in any tryout, conditioning workout, practice, or competition. This policy may pay for costs not covered by your primary health insurance. The following conditions must be met for possible coverage by the secondary insurance: 1) The injury must have occurred during participation in a supervised regularly scheduled game, practice, or workout (summer camps are not covered under this policy). 2) The injury was reported to the Northern Arizona University Athletic Training Room within 24 hours of the injury occurance and recorded in an injury report or on your treatment record. 3) You have ninety (90) days, from the date of the injury, to meet the secondary insurance deductible of $1, The secondary insurance will then consider paying for costs up to two (2) years after the date of injury. If the costs for the injury do not reach $1,000.00, the athlete is responsible for all charges. 4) Copies of itemized bills and insurance explanation of benefits or denial of payment forms must be presented to the Medical Service Coordinator within sixty (60) days of reaching the secondary insurance deductible. Bills, for costs, after the deductible has been reached, must be submitted to the Medical Service Coordinator within sixty (60) days of the billing date. Northern Arizona Universities secondary athletic insurance policy will not cover the following: 1) Any pre-existing medical conditions, injuries, surgeries, or bracing. 2) Ordinary illnesses and general prescriptions. 3) Injuries received outside of participation in a supervised, regularly scheduled game, practice, or workout. 4) Medical charges that are found to be over and above usual and customary for the area of service. 5) Injuries sustained while substance abuse or misuse is occurring. Northern Arizona University will not be responsible for: 1) Charges that are declined by any and all insurances. 2) Late charges or charges associated with noncompliance or falsification of information. I have received and read the Northern Arizona University Athletic Insurance Participation Policy and understand the responsibility of the athlete to maintain a primary health insurance and the responsibility of the University to a student athlete who becomes injured as a result of participation in intercollegiate sports at Northern Arizona University. Northern Arizona University reserves the right to verify signatures and policy information. (Signature of Policyholder) (The policyholder must sign both sides of this form) (Signature of Guardian if different than Policyholder and student athlete is under 18 years of age) (must sign both sides of form) (Signature of Student Athlete) ( he athlete must sign both sides of this form) This is only a brief summary of the Northern Arizona University Athletic Insurance policy and benefits. The policy is kept on file and can be reviewed in the Northern Arizona University Athletic Training Room. If you have questions regarding primary insurance responsibilities or secondary insurance coverage, please contact: Athletic Training Medical Service Coordinator at NAU Dept. Athletics PO Box 15400, Flagstaff, AZ Phone , fax NORTHERN ARIZONA UNIVERSITY ATHLETIC DEPARTMENT SECONDARY HEALTH and DENTAL INSURANCE INFORMATION

5 (Please type or clearly print all information) Student Athlete Sport(s) Secondary Health Insurance Is your policy an HMO, PPO, or Managed Care Plan? No ( ) Yes ( ) Primary Care Physician Phone number Except for emergency situations, are you required to get a referral to see any health care provider other than your Primary Care Physician or Insurance Company Clinic? No( ) Yes ( ) If your Primary Care Physician or Insurance Company Clinic is not located in the Flagstaff area, are there any participating physicians, clinics, or medical facilities in the Flagstaff area? No ( ) Yes ( ) Flagstaff area Provider Phone Number Will a change in the athlete s enrollment status (full -time student to part-time student) change the athlete s insurance coverage? No ( ) Yes ( ) Is the student athlete covered by another health insurance policy? No ( ) Yes ( ) If yes, please provide the same information for the second policy as asked above. Dental Insurance I agree that the information provided is accurate and complete to the best of my knowledge. I agree to notify the Northern Arizona University Athletic Training Department of any changes in insurance coverage. I/We grant permission for medical personnel to provide treatment in emergency situations. (Signature of Policyholder) (Signature of Guardian if different than Policyholder and student athlete is under 18 years of age) (Signature of Student Athlete)