7/28/2019 Claims - How to File a Claim (Rev Mar 2009)

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 HOW TO FILE A CLAIM 

Outpatient Claims: -

Pl ease submi t al l or i gi nal bi l l s t oget her wi t h of f i ci al r ecei pt s and make sur e

t he f ol l owi ng i nf or mat i on/ document s i s/ ar e i ncl uded:a) “Cl ai m Submi ssi on Sl i p” wi t h Name of pat i ent , Member No. and Pol i cy No.b) Doctor / Ser vi ce provi der name and address i ncl udi ng t he count r y where

servi ce was r enderedc) Dat e of t r eat ment / vi si t wi t h di agnosi s or name of i nj ur yd) Detai l ed br eakdown of char ges/ servi ces wi t h act ual char ges pai d wi t h

of f i ci al recei pts .

Not e: Phot ocopi es or comput er pr i nt out s f ur ni shed by your ser vi ce pr ovi der wi l lnot be accept ed. For U. S. A. servi ce pr ovi der , HCFA- 1500 For ms wi t hdoct or ’ s si gnat ur e wi l l be accept ed

Hospital Claims: -

Pl ease submi t al l or i gi nal bi l l s t oget her wi t h of f i ci al r ecei pt s and make sur e thef ol l owi ng i nf or mat i on document i s/ ar e i ncl uded:a) A compl et el y f i l l ed i n “Not i f i cat i on of Cl ai m For m”b) Name of pat i ent , Member No. and Pol i cy No.c) Dat e of hospi t al admi ssi on and di schar ged) Di agnosi s of di sabi l i t y r equi r i ng t he hospi t al i zat i on and name of sur gi cal

pr ocedur es per f ormed ( i f any)e) I t emi zed charges/ det ai l ed br eakdown of char ges.

Claims for Optional Benefits:

Dental Claims: -

Pl ease submi t :a) Or i gi nal bi l l s and of f i ci al recei ptsb) A compl et el y f i l l ed i n “Dent al Cl ai m For m”. The dent i st i s r equi r ed t o

mark t he area of oral t r eat ment on t he dental char tc) I t emi zed chargesd) A compl et ed or al exami nat i on r epor t i s r equi r ed f or submi ssi on of t he f i r st

dent al cl ai m.

Personal Accident Claims: -

Pl ease submi t :a) Or i gi nal bi l l s and of f i ci al recei ptsb) Hospi t al / Physi ci an’ s r epor t s gi vi ng det ai l s on t he nat ur e of t he i nj ur y and

t he extent and per i od of di sabi l i t y, pol i ce r epor t wher e r el evant and i f deat h shal l have r esul t ed, a compl et ed “Cl ai m For m - Deat h”, “At t endi ngPhysi ci an’ s Stat ement f or Deat h Cl ai m”, a copy of t he deat h cer t i f i cat e andt he rel evant cor oner ’ s r epor t .

IMPORTANT NOTES:

I f t he cl ai m document s ar e not suf f i ci ent f or cl ai m adj udi cat i on, Pacific CrossInsurance Company Limited or its Third Party Administrator r eser ves t he r i ght s t or equest f ur t her i nf or mat i on or a “Not i f i cat i on of Cl ai m For m” f r om t he cl ai mantt o f aci l i t at e t he cl ai m assessment pr ocess.

Al l cl ai ms must be submi t t ed t o us wi t hi n 90 days f r om t he dat e of ser vi cesr endered. Any cl ai ms submi t t ed more t han 365 days af t er t he date of servi ce are

not payabl e.

As our comput er syst em operat es i n Engl i sh, you wi l l r ecei ve r ei mbur sementqui cker i f t he cl ai m document s ar e i n Engl i sh.

Rev 03/2009