



免费预览已结束,剩余1页可下载查看
下载本文档
版权说明:本文档由用户提供并上传,收益归属内容提供方,若内容存在侵权,请进行举报或认领
文档简介
Claim Filing Instructions & Claim FormPlease follow these instructions prior to filing a claim and when completing the Claim Form. Assistance is also available from the International Medical Group (IMG) Customer Service Department at the telephone numbers listed below.IF YOU HAVE NOT YET RECEIVED TREATMENT:Pre-certification (notification of illness or accident): You must call IMG to pre-certify any of the following conditions: any treatment requiring hospitalization; outpatient surgery, CAT scans, MRIs; within 48 hours after an emergency admission to the hospital; care in an extended care facility; home nursing care; durable medical equipment including artificial limbs; or transplants. Pre-certification may be done by you, a relative, or a hospital representative.Independent Preferred Provider Organization (PPO): Your plan may recommend you receive treatment from a provider within the US PPO. You may access a listing of physicians or facilities by:Using the IMG website, . This provides a complete listing of providers by specialty and geographic location.Contact the IMG Customer Service Department at the telephone number or mailing address listed below for a list of providers in your area. Please note, due to the size of the PPO network we can only send directories for your immediate area.When receiving treatment from a PPO provider, please follow these instructions:Present your IMG medical identification card to the provider.Request that the provider send the bill directly to IMG. Please note, if you pay directly to the provider for an eligible expense this will likely affect your reimbursement from IMG. The negotiated fee for services will be the maximum reimbursement, whether paid to the provider or to you.Complete the Claim Form and submit it with all original bills or invoices. If the provider has filed the claims on your behalf, simply forward the completed Claim Form to IMG.When receiving treatment from a PPO provider for eligible expenses, the submitted bills must be re-priced through the PPO to the negotiated rate. This procedure may extend the normal processing time of your claim.IF YOU HAVE ALREADY RECEIVED TREATMENT:If this is a new claim, complete ALL PARTS of the Claim Form. If treatment was received in the United States you do not need to complete PART C.If this is a continuing claim, complete PARTS A AND D. If treatment was received outside of the United States, you should also complete PART C. Attach all original itemized bills, statements and invoices for services and supplies. Please make certain that all documents indicate claimants name, date of service, diagnosis and the itemized charges.*Overnight packagesshould be sent to:2960 North Meridian Street, Indianapolis, IN 46208Mail the completed form to*:International Medical Group, Inc.Claims DepartmentP.O. Box 88500Indianapolis, Indiana 46208-0500 USAFor additional assistance:Phone:1-800-628-4664 (In US)1-317-655-4500 (Outside US) Fax:1-317-655-4505Email: Web: Our goal at IMG is to process your claim quickly, accurately and efficiently. In order to achieve this, the Claim Form must be fully and accurately completed. Failure to do this will result in processing delays. Page 1 of 5 Claim Form & Authorization DIRECTIONS FOR SUBMITTING A CLAIM (There are four parts to this form A, B, C & D. Please carefully review the instructions below.) If this a new claim, complete ALL PARTS of this form. If treatment was received in the United States you do not need to complete PART C.If this is a continuing claim, complete PARTS A AND D. If treatment was received outside of the United States, you should also complete PART C. Attach all original itemized bills, statements and invoices for services and supplies. Please make certain that all documents indicate claimants name, date of service, diagnosis and the itemized charges.Mail to:International Medical Group, Inc.Claims DepartmentP.O. Box 88500Indianapolis, Indiana 46208-0500 USAPhone: 800.628.4664 or Outside US 317.655.4500Notice: Any false statement, concealment or fraud shall render this insurance null and void and all claims hereunder shall be forfeited.PART A. To be completed and signed by the Claimant for all claims. (as appears on ID card)Claimant/Patient Name: mo /day /yr Male Female Date of Birth: Claimants Relationship to Primary Insured Self Spouse Child Other (as appears on ID card)Name of Primary Insured: mo /day /yr Male Female Date of Birth: Home Country Address:Current Address:Home Phone: Work Phone: E-mail: Group # : ID # : Are you in school full-time? Yes No If yes, please provide name of school and the address:Are you a U.S. Citizen? Yes No How many months of the year are you in the U.S.? If Claimant is covered by another plan, complete items below. (as appears on ID card) Name of Primary Insured: mo /day/yrDate of Birth: Group # of other plan : ID # of other plan : Mailing address Name of other carrier City Carrier address State Postal Code City Name of employer State Postal Code Page 2 of 5PART B. To be completed by the Claimant for new claims only. (If you need additional space, please attach a separate sheet.)1. How did the condition begin? State fully all symptoms and describe the condition in detail from the beginning. For accidents, include how, when and where the accident occurred. mo / day / yr2. When did the first symptom of this condition begin? State the exact date if possible. 3. Have you ever had or been treated for this type of injury or illness before? Yes No 4. List all the names and addresses of the providers you have seen for this condition.5. What ailments, diseases, illnesses or injuries have you experienced during the last five years? Please provide the name and/or description of each condition, dates and name and address of the attending physician(s).6. Is this condition the result of an accident or illness:a. Related to employment? Yes NoIf yes, are you applying for Workers Compensation benefits? Yes Nob. Involving a motor vehicle? Yes NoIf yes, please list the names of involved parties, insurance carriers and policy numbers. c. Was a police report filed? Yes NoIf yes, please identify the Police Department where it was filed.Page 3 of 5PART C. Complete for all treatment received outside of the United States.Date of servicemm/dd/yrProviderWhat type of service and/or name of drug provided?What was the illness/injury?City/countryType of currencypaid or billedTotal chargepaid or billedConverted to US fundsOffice use onlyPART D. Authorization - to be completed by the Claimant for all claims. This section must be signed by hand.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 International Medical Group, Inc. or any agent or administrator acting on its behalf.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.Print Name of Insured Signature of Insured/Guardian_ Date AUTHORIZATION: I authorize payment of medical benefits to the doctor or other supplier of services submitting the attached bills.Signature of the Insured/Guardian_ Date Page 4 of 5PRIVACY AND CONFIDENTIALITY RELEASE FORMBy completing this form, you are providing your consent to IMG to discuss your claim activity with the person(s) listed below. Without this release form, IMG cannot discuss your claims activity with anyone other than your physician(s) or provider(s) of service. This section must be signed by hand. I authorize IMG to discuss my claim activity with . This authorization is valid for months from the date signed.I give IMG permission to release any or all of the following information:(Please select and initial)All financial and claim information related
温馨提示
- 1. 本站所有资源如无特殊说明,都需要本地电脑安装OFFICE2007和PDF阅读器。图纸软件为CAD,CAXA,PROE,UG,SolidWorks等.压缩文件请下载最新的WinRAR软件解压。
- 2. 本站的文档不包含任何第三方提供的附件图纸等,如果需要附件,请联系上传者。文件的所有权益归上传用户所有。
- 3. 本站RAR压缩包中若带图纸,网页内容里面会有图纸预览,若没有图纸预览就没有图纸。
- 4. 未经权益所有人同意不得将文件中的内容挪作商业或盈利用途。
- 5. 人人文库网仅提供信息存储空间,仅对用户上传内容的表现方式做保护处理,对用户上传分享的文档内容本身不做任何修改或编辑,并不能对任何下载内容负责。
- 6. 下载文件中如有侵权或不适当内容,请与我们联系,我们立即纠正。
- 7. 本站不保证下载资源的准确性、安全性和完整性, 同时也不承担用户因使用这些下载资源对自己和他人造成任何形式的伤害或损失。
最新文档
- 第3课 常见的数据类型(教学设计)赣科版四年级上册信息技术
- 12.3 角的平分线的性质 教学设计 人教版八年级数学上册
- 2025年区块链技术在供应链管理中的变革
- 工作界面的基本操作说课稿-2025-2026学年中职专业课-数控技术应用-装备制造大类
- 安全员考试试题及答案2025
- 2025年《中级会计实务》真题附答案
- 2025广安教师招考试题及答案
- 2025年医院核心制度查对制度考试试题(答案+解析)
- 2025医院噪声考试题目及答案
- 2025年医院三基考试药学考试题目及答案1
- FBS-GC-001-分布式光伏施工日志
- 月考试卷讲评课课件
- 读书分享读书分享哈利波特
- 游戏:看表情符号猜成语PPT
- 影视鉴赏-第一章-影视鉴赏的基本概念
- 电厂安全生产运行管理培训课件
- 医院院前急救病历 广州市急救中心
- 输液室运用PDCA降低静脉输液患者外渗的发生率品管圈(QCC)活动成果
- 数星星的孩子习题精选及答案
- 摩登情书原著全文下载(通用3篇)
- 材料科学基础复习题及答案
评论
0/150
提交评论