Claims

Tips for getting your claim paid

We are sorry you have been injured or find yourself diagnosed with an illness. If you want assistance we are here to help you take full advantage of your employee insurance benefits. You must submit all required information to the insurance carrier, to ensure your insurance company pays the claim in a timely manner.

Below you will find several tips that have proved to help get claims processed and employees paid fast:

Group, Policy and/or Certificate Number: Insurance companies are not aware of your situation, unless you file a claim and bring it to the attention of the insurance company or carrier. For the insurance company or companies to pay you the appropriate amounts, you must be able to provide a group, policy and/or certificate number for each of your employee benefits.  If the insurance carrier can not identify you in their system, you will not be paid.

Type of Coverage: You must be aware of the types of employee benefits and insurance coverage you have for yourself or family.  The benefit definitions clearly define each policy provision and what types of injuries or illnesses are covered.  Most insurance policies include exclusions and/or types of incidents or illnesses that are not covered. If you feel there is any way an insurance benefit could be paid, we always recommend submitting the claim.  

Instructions: Be sure to read the instructions fully and follow them explicitly. You will likely need the following items:

• Group, policy, and/or certificate number
• Date and location of injury or diagnosis
• Itemized billing from health care provide or facility
• Physician’s notes or operative report confirming diagnosis
• Diagnosis codes for qualified claims
• Physician’s contact information
• Accident / police report
• Your signature
• Your physician’s signature
• Your employer’s signature (disability)

Method of delivery: File your claim electronically or by phone if possible. Many insurance carriers and employee benefit vendors will allow you to start the claim process by phone or online. The insurance company will then email or mail the required forms and documentation to the policyholder. Avoid mailing forms and documents if possible. Keep copies of all your documentation, just in case the carrier misplaces your documents.

Additional Information: Many times an insurance company or carrier will require additional information. It is your responsibility to respond to the request for additional information in a timely manner. Some examples:

• The Health Care Financing Administration form, or HCFA 1500, which is the standard form used by doctors and other providers when submitting bills or claims for reimbursement.

• The Uniform Billing form, or UB-04, a uniform-billing claims form used by hospitals, clinics, ambulatory surgery centers and rehabilitation centers.
• An authorization form that expedites the claims process by allowing your insurer to contact your medical providers.

Special notes:

• Employees should not complete the physician’s or employer’s section of the claim form
• Claim form should not be dated prior to first date of disability
• Physician portion must have a first date of disability and a return date to work or a next appointment date
• Supporting documentation is not always required to collect a wellness benefit

If you would like BenefitSimply to assist with your claim, be sure to complete the HIPAA release.