Insurance Claim Process

Transcription

1 Insurance Claim Prcess Caches and Managers, It is yur respnsibility t prvide this infrmatin t yur parents. If a player injured in-seasn while participating in an FC Smers sanctined event Medical Insurance and Secndary Insurance is available. Instructins t cmplete insurance claims can be fund belw and in the attached dcumentatin. Smers Yuth Sprts Organizatin (SYSO) - Medical and Secndary Insurance Instructins: Parent cmpletes frm and attaches necessary dcumentatin Parent brings frm t President - FC Smers fr signature Parent mails r faxes file t insurance carrier See attached, SYSO Accident Claim Frm Prcedures, fr cmplete details. Eastern New Yrk Yuth Sccer Assciatin (ENYYSA) - Secndary Insurance, $500 deductible. Instructins: Cach cmpletes frm with assistance f Parent Cach , mails r faxs t:!! Lee D Argeni Registrar - WYSL 271 Nrth Avenue; Suite #206 New Rchelle, NY [email protected] Fax: (914) See attached, Advance Ntice f Injury/Claim Frm Prcedure, fr cmplete details. Helen Brady, President-FC Smers. Nv. 2013

2 CHARTIS Accident & Health Claims Department PO Bx Shawnee Missin. KS Telephne Facsimile Date CHARTISG- Dear Plicyhlder, Attached is a cpy f the Special Risk claim frm yu requested. Please read the fllwing infrmatin and in$tructins very carefully as all f the infrmatin is required fr us t begin reviewing yur claim. Each persn filing a claim will need t submit a separate claim frm. All sectins f the claim frm must be cmpleted in detail paying special attentin t the fllwing: Please ensure that yu cmplete the sectin n Hw, When and Where Accident Occurred t include the Date and Time f the accident. Please ensure that the Plicyhlder signs at the bttm f Sectin A Please ensure that the claimant (injured party) signs at the bttm f the claim frm Attach itemized bills prvided by the prviders/facilities (HCFA 1500 fr Prviders and UB92/UB04 fr facilities) fr all medical expenses being claimed which must include the fllwing: Claimant' name Cnditin being treated (Diagnsis/Diagnsis Cdes) Descriptin f services rendered (Standardized Prcedure Cdes) Dates and Charges fr each service prvided Prvider's Federal Tax Id Number If yur plicy is an Excess plicy (meaning yu have ther primary insurance), we will need the Explanatin f Benefits (EOBs) frm yur primary insurance cmpany cnfirming what they have paid sent in with the claim frm and itemized bills Once yur claims package is received, it will take apprximately business days t review yur claim. Failure t submit all requested dcuments culd result in a delay f the claims prcess. Please keep in mind that all decisins regarding claims will be made by the Claims Department and will be based n the dcumentatin prvided when the claim is filed. If yu have questins/cmments, please cntact ur Custmer Service Department at Regards, Custmer Service Department Chartis Accident &Health

3 PROOF OF LOSS CHARTIS NAME OF GROUP: Smers Yuth Sprts Organizatin Accident & Health Claims Department P. O. Bx Shawnee Missin, KS POLICY NUMBER: (Telephne) SRG (Facsimile) SPECIAL RISK ACCIDENT AND SICKNESS CLAIM FORM INSTRUCTIONS: 1.) Yu must have SECTION A fully cmpleted by a designaled fficial f the Plicyhlder. 2.) SECTION B is t be cmpleted, signed and dated by the claimant r parent/guardian f claimant, if claimant is a minr. 3.) AHach itemized bills fr all medical expenses being claimed including the claimant's name. cnditin being treated (diagnsis), descriptin f services, date f service(s) and the charge made fr each service. PLEASE MAIL COMPLETED FORM AND BILLS TO ABOVE ADDRESS. primary plan - benefits are payable fr cvered medical expenses frm EXCESS plan - Eligible cvered expenses will be detennined after benefits have been paid by ther the first dllar withut regard t payments made by ther insurance up t the plicy maximum. valid and cllectible insurance. Yu must submit yur claim t yur ther insurance cmpany first. When yu receive their Benefit Statement (EOB) send it t us alng with the itemized bills, Benef!l.s fr eligible expenses will be paid per plicy tenns. The fumishing f this fnn, r its acceptance by the Cmpany, must nt be cnstrued as an admissin f any liability n!he Cmpany, nr a waiver f any f the cnditins f the insurance cntract. SECTION A MUST BE COMPLETED AND SIGNED BY A DESIGNATED REPRESENTATIVE OF THE POLICYHOLDER NAME! ANDIOR LOCATION OF GROUP/CLUBISPORT/SCHOOL, ETC. CLAIMANTS FULL NAME (PLEASE PRINT CLEARLY OR TYPE) ISOCIAL SECURtTY. (IF AVAILABLE) INAME OF SUPERVISOR B I U.S. CITIZEN I DATE OF BIRTH I DATE COVERAGE BEGAN I DATE COVERAGE WILL END/HAS ENDED DYes 0 N 04/30/ NATURE OF INJURY OR ILLNESS, (DESCRIBE FULLY. INCLUDING WHICH PART OF BODY WAS INJURED,) IDESCRIBE HOW. WHEN AND WHERE ACCIDENT OCCURRED (DATE AND TIME), NAME OF ACTIVITY INDICATE THE SPORT (IF APPLICABLE) DID ACCIDENT OCCUR: A, WHILE CLAIMANT WAS SUPERVISED B. DURING SPONSORED ACTIVITY C. DURING PROGRAMMED HOURS D. WHILE TRAVELING TO OR FROM REGULARLY SCHEDULED ACTIVITY IN A SUPERVISED GROUP DATE LAST WORKED DATE RETURNED TO WORK I WEEKLY EARNINGS POLICYHOLDER REPRESENTATE NAME(PLEASE PRINT) SIGNATURE OF POLICYHOLDER REPRESENTATIVE DAYTIME TELEPHONE NUMBER DATE SECTION B MUST BE COMPLETED DO YOU HAVE OTHER HEALTH INSURANCE yesd ND LIST NAME. ADDRESS, AND PHONE # OF OTHER INSURANCE COMPANIES UNDER WHICH CLAIMANT IS POLICY #laccount # INSURED: IF CLAIMANT IS A MIR. NAME OF CLAtMANT'S GUARDIANIRELATIONSHIP TO CLAIMANT SOCIAL SECURITY NUMBER I DATE OF BIRTH I Male U. S. Citizen Female DYes 0 N ADDRESS OF CLAIMANT (IF CLAIMANT IS A MIR, NAME AND ADDRESS OF CLAIMANT'S GUARDIAN) GUARDIAN'S SOCiAl SECURITY NUMBER NAME!ADDRESSITELEPHONE # OF EMPLOYER (IF CLAIMANT IS A MIR, GUARDIAN'S EMPLOYER) EMPLOYER'S DAYTIME TELEPHONE # I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KWLEDGE AND BELIEF. AUTHORIZATION and ASSIGNMENT OF BENEFITS I, the undersigned authrize any hspital r ther medical-care institutin, physician r ther medical prfessinal, phannacy, insurance supprt rganizatin, gvemmental agency, grup plicyhlder, insurance cmpany, assciatin, emplyer r benefrt pian administratr t fumish t!he Insurance Cmpany named abve r its representatives, any and all infnnatin with respect t any injury r sickness suffered by, the medical histry f, r any cnsultatin, prescriptin r treatment prvided t, the persn whse death, injury, sickness r lss is the basis f claim and cpies f all f that persn's hspital r medical recrds, including infnnatin relating t mental illness and use f drugs and alchl, 10 detennine eligibility fr benefit payments under!he POliCY Number identified abve. I authrize the grup plicyhlder. emplyer r benefit plan administratr t prvide the Insurance Cmpany named abve with financial and emplyment-related infnnatin. I understand that this authrizatin is valid fr the term f cverage f the Plicy identified abve and that a cpy f this authrizatin shell be cnsidered as valid as the riginal. I understand that I r my authrized representative may request a cpy f this authrizatin. I authrize payment f medical benefits t the physician r supplier fr service perfrmed. Califrnia :Fr yur prtectin, Califrnia law requires!he fllwing t appear n this fnn: Any persn wh knwingly presents a false r fraudulent claim fr the payment f a lss is guilty f a crime and may be subject t fines and cnfinement in state prisn. Rhde Island: Any persn wh knwingly presents a false r fraudulent claim fr payment f a lss r benefit r knwingly presents false infnnatin in an applicatin fr insurance is guilty f a crime and may be subject t fines and cnfinement in prisn Fr residents f New Yrk: Any persn wh knwingly and with intent t defraud any insurance cmpany r ther persn files an applicatin fr insurance cntaining any materially false infrmatin. r cnceals fr!he purpse f misleading, infnnatln cncerning any fact material theret. and any persn wh knwingly makes r knowingly assists, abets, slicits r cnspires with anther t make a false reprt f the theft, destructin, damage r cnversin f any mtr vehicle t a law enfrcement agency, the department f mtr vehicles r an insurance cmpany cmmits a fraudulent insurance act, which is a crime, and shall als be subject t a civil penalty nt t exceed five thusand dllars and the value f the subject mtr vehicle r stated claim fr each vilatin. Fr residents f Pennsylvania: Any persn wh knwingly and with intent t defraud any insurance cmpany r ther persn files a statement f claim cntaining any materially false infnnatin r cnceals fr the purpse f misleading, infnnatin cnceming any fact material theret cmmits a fraudulent insurance act, which is a crime and subjects such persn t criminal and civil penalties. Fr claimants nl residing in Califrnia. Rhde Island. New Yrk. r Pennsylvania: Any persn wh knwingly presents a false r fraudulent claim fr payment f a lss r benefit r knwingly presents false infrmatin in an applicatin fr insurance is guilty f a crime and may be subject t fines and cnfinement in prisn. CLAIMANT OR AUTHORIZED PERSON'S SIGNATURE DATE

4 SYSO - ACCIDENTIINJURY REPORT PARTICIPANT INFORMATION Persn Injured Date f Birth Address, Hme Phne# Additinal Cntact# Parent/Guardian Name ACCIDENT INFORMATION Date Time Lcatin Nature f Injurv Cause f Injurv Cntributing factrs (if any) Was First Aid administered n site? Yes N Ifyes abve explain Additinallnfrmatin PHYSICIAN INFORMATION Name Phne# Address SYSO INFORMATION Signature f Persn Making Reprt'--- Date Signature f Cmmissiner Receiving Reprt Date Please Nte: all reprts must be frwarded t the Smers Yuth Sprts Org., Attn: President, 108 Village Square Bx 302, Smers, NY 10589

5 SYSO - ACCIDENT CLAIM FORM PROCEDURES Each persn filing a claim will need t submit a separate claim frm. All sectins f the claim frm must be cmpleted in detail. Please ensure that claim frm is signed where indicated as n claims can be prcessed withut the claim frm being cmpleted in its entirety. The SYSO Cmmissiner fr the partcipant's sprt must als sign the frm. Medical Claims: Balance due statements frm the medical prviders are nt acceptable. Claimants must submit dcumentatin n itemized insurance billing frms prepared by the medical prvider r facility where treatment/services were rendered. A medical prvider wll prvide a HCFA1500 Frm and a facility (hspital) will prvide a UB92 frm. Fr Excess Plicies: If yu have primary medical cverage under anther plicy, yu must submit a cpy f the crrespnding Explanatin f Benefits statement frm yur primary insurance carrier in additin t the itemized insurance bills. Mail the claim frm and the supprting dcuments t the claims ffice listed n the claim frm. Once yur claim package is received, it will take apprximately business days t review and prcess. Please keep in mind that all decisins regarding claims will be made by the Claims Department and will be based n the dcumentatin prvided when the claim was filed. If yu have any questins/cmments, please cntact Custmer Service Department at , Mnday thrugh Friday, between the hurs f 8am t 8pm EST.

6 Eastern New Yrk Yuth Sccer Assciatin, Inc. Affiliated with ENYSASA USYSA USSF FIFA 53 Nrth Park Avenue, Suite 207, Rckville Centre, New Yrk ENYYSA Fax ADVANCE TICE OF INJURY NAME: ADDRESS: CITY: STATE ZIP CODE PHONE #: SOCICAL SECURITY #: CLUB: TEAM: DATE OF INJURY: TIME: PLACE TYPE OF INJURY: HOW DID INJURY OCCUR: DOES THE INJURED PLAYER HAVE PRIMARY INSURANCE? COACH: PHONE # NAME OF CLUB OFFICIAL: POSITION: SIGNATURE OF CLUB OFFICIAL DATE AFTER COMPLETING THE ABOVE, PLEASE SEND THIS FORM TO YOUR LEAGUE OFFICE. LEAGUE APPROVAL