AmeriCorps Medical Benefits - Claim Instructions

AmeriCorps Medical Benefits - Claim Instructions

AmeriCorps Medical Benefits
- Claim Instructions
-- -- -- Any person who MOA igty and v d intent to nj.re, aeftard waecere any 'ns-rance mmpany oroder person 6 es an applmton for ins~rance stalerent ol da m mnb n ng any matena y fase
inlormaton or mncea's, for me p
r
wof m sleaong, nfomnonm c e m ng any fan matea mereto mmmu, a tra~d. e n nsLrance act MI ch s a c m ano s.b.em s-cn person to mm na, and
dvii penalties.
Attention A r k a m , Louisianaand West Virginia Residentr: Any personwho krowingiy pmentsa falseorfraudulentdaii for paymentofa k s w benefior lolwdngly presentsfalsa
infombbn in an applicahn for insurance isguiltyofa aimeand may be subject to fines and confinementin prison.
Attention California, Ohio and Pennsylvania Residents: Any personwho knowinglyandwith intent to defraudany insurancemmpanywothsperson files an applicah fw insuranceor
statement of claim mntaining any materiallyfaise informabonor conceals, for the purpose of misieading, infomtion concerningany factmateMl thereto commits a fraudulent insurancead which is
a crime and subjects such person to criminal and civil penalles.
Attention Colorado Residents: it is unl&l to knowingly provide false, inmmpkte, or misleadingfactsor informationtoan insurancecompany f o r k purposeofdefmudingor attemplng to
defraud the mmpany. Penaltiesmay include imprisonment,fines, denial of insurance, and dvil damages. Any insurancempany a agent of an insuranceampanywho knowingly pvhdesfalse,
inmmplete,or misleading facts or information toa policyholderordaimant fwthe purpxe ofdetrauding or attemphngtodefraud policyholder ordaimant with regard to a sefflement w award
payable from insurance proceeds shall be reportedto the Colorado d ~ s iofi insurancewithin the deparbnent of regulabyagencies.
Attention Florida Residents: Any personwho knowingly and with intent to injure, defraud, or deceive any insurer, fiiesa statement ofdaim or an a p p l i d n mtaining any false, incompletea
misleading informalon is guiky of a febny of h e third degree.
Attention Kansas Residents: Anv personwho knowinalvandwith intent toiniure, defraud ordeceiveanv insurancemmpanvorother m n submits an enrollment form for insurances
statement of a i m mntainingany lidtenally false infomdim ormnceais, for ltiepurpose of misleading,i i f o m b m mceming any factinater$lthereto may havevidated state law.
Attention Kentucky Residents: Any person who knowinglyand with intentto defraudany insurancemmpany orothw p n filesan application for insurancew statement of&im mntaining any
materiallyfalse information or mnceais, for the p. u. m of misleading, infmation mnceminq.any. fact materialthereto mmmitsa fraudulent insuranceacl which isa crime and may. s u.W such
I personto aiminal and civil penaibes.
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Anention Maine and Tennessee Residents: It is a aimeto knowingly pwkdefalse, inmmpletearmkkadinginformab toan insurance company fwhe pups? of defraudingthe mmpany.
Penallesmay include imprisonmentfines or denial of insurance benefits.
Attention New Jersey Residents: Any person who indudesany false or misleading infomm on an applicadan foran mv~rancepolicy or knahinglyfiles a statement of claim mtaining any false
nr miclpldinn infnmatinn .i+e , h i d to
wn~ltipr.
- rnmilul and &I r-..-..-Anenton North Carolina Residents. Any person who molanngty an0 wnh ntwnto i n p , aefia~dw dece e any insJrance mmpany or othw penon fiesan apptcaton for nsJrdnceorstanwnent
of
-' ca m mna n y any matenaly lase nformatonor mrcea s for de p u m of msleao ng, nformaton mncem ng any fact matenalthereto mmmtsa traLd~emns-rance act, h'ch may t e a
airne and subjects such person to aiminal and dvil penalles.
Attention Oklahoma Residents: WARNING: Any person who M&!ty, a n d m intent to injure, dehaud or dece'many insurer, makes any daimfork proceedsofaninsurance policy
mntaining any faise, inmmpleteor misleading infmabon is guiltyofa felony.
Attention Oregon Residents: Any personwho with intent to injure, defrauda deceive any insurancecompany or oths parsonsubmits an enrollmentform f~ insurancew statement ofdaim
conlining any materiallyfalse informationor mnceals for the purpose of misleading, infomtion mnceming any fact materialthereto may have wlated state law.
Attention Puerto Rim Residents: Any personwho knowinglyandwith the intenhn to defraud indudes false infonation in an arnicationfor insurance or Re, assistor abet in the filing ofa
fraudulentclaim toobtain paymentofa loss or other benetit or files more than oneciaim for the same icssor damage, m i t s a felony and iffoundguikyshalibe punished faeach violatnn with a
fine of no less than We thousand dollars 1$5.0001,not to exceed ten housand dollars 1$10.WO): wim~risonedfor a fued term of three 131vears, or both. Ifawram6na circumstancesexist he bed
jail term may be increased to a maximumoifive i5) years; and #mitigatingdmmstan'ces are piesent; the jail term may be reduced to a %nimu'moftwo (2) @
s.ar"
Attention Vermont Residents: Any person who knowingly and wih intent to injure, defraud ordmive any insurancemmpany or other penon files an applicalon for insuranceor statementof
claim mntainina any matMallvfalseinformahnor mnceals, forthe ou,umoseof misleadina, infombbn mnceming
- any. fact material thereto commits a fraudulent insuranceactwhich mav be a
mme ard mafs~b'ec! s.cn derson to cnmm an0 m pelaoes
Attention Virginia Residents: Any person nro nno.ilng y an0 8 m nlenl to n,.re. aefra-d ordeceve any ms-rance mmpany aomer p n 6 es an app caton for nsJrance or naement of darn
mnb r.4an, malena ,lase informaloncr mncea s. for ire perposeof m slead ng, .nfwmanonmncemnganlfan matenalWerommmb a had. ent a u *him sa cnme and s ~ o such
m
personticriminal and civil penal8es.
Anention Washington Residents: It is a aim to knowinglypmtdefalse,mmmplete, or misleading infonat'on to an insurancecompeny f o r k purpaseof defraudingtheampany. PeaHies
nc.oe mpnsolmeii fines an0 oenia,of ns-rance benefit,
hOTE INCOMPLETECLAIM FORMS WILL BE W R h E D T O YOU FOR MISSINGINFORMATION. M I S WILL DELAY THE PROCESSINGOFTHE CWM. FOR FASTER, EASIER
SUBMISSION OF CLAIMS. THE PROVIDER MAY COhTACTTHE AETNACLAIM PROCESSING CENTER FOR INFORMATIONREGARDING ELECTRONIC CLAIM SUBMISSIONS
TO THE MEMBER
1. Complete blocks 1-16 in full.
2 Complete o~ocks17-18 on y if omer medical werage exists.
3. Be cena n to s gn the a~tnoizalon to re ease informaon Block (19).
4. If YOL n.sh lo have vour oenefts for ths cla:m oaio o.redv to vour onvsician or s~oolier,s~anblock 1201.
5. if you have submittid a request for benefits to another plan, ir;clud;ng~edicare, a'&ch a copy of the i l l s you submitted to the other plan and the explanation of benefits you
received from the other plan.
6. Attach itemized bills or ask your health care provider to complete theapplicable section on the reverse side. The bills must include:
patient's name
date($ of service(s)
condition being treated
relationshipto member
type of se~ice(s)rendered
If this information is missing, write it on the bill and sign your name.
7. If prescriptiondrugs are covered under your plan, submit receipts or a Prescription Drug Remrd form. Recaipt must contain:
drug name
strength
dose perlday
prescription number
charge
quantity
- purchase date
physician's name
- nature of illness or injury
pharmacy nameladdress
This informationcan be ca~iedfrom the orescriotion
bottle or box.
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8. Reta n wpiesot )our oills for your record.
9. Sen0 tne completed benefils rewest and the bills lo: SRC, an Aetna Company
Ann: Claim De~artment
P.O. BOX 2390;
Columbia, SC 29224-3907
Fax to: 1-803-333-1402
Phone: 1-888-772-9682
TO THE PHYSICIAN OR SUPPLIER
1. Complete items 21-40 in full.
2. It the employee indicates that benefits should be pas directly to the physician or supplier, then these benefits will be sent directly to you with an information copy of the
transactionsto the member.
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GC-15920 (11-06)
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Mail to:
AmeriCorps Medical Benefits Request
TO BECOMPLETED BY MEMBER
1. AmeriCorps Program Name
SRC, an Aetna Company
Attn: Clalm Department
P.O. Box 23907
Columbia. SC 29224-3907
Fax to: 1 $ 0 3 < 3 3 i 4 0 2
Phone: 1-888-772-9682
2. PolicyiGroup Number
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3. Membefs Aetna ID Number
4. MembefsName
6. MembetsAddress (include zip mde)
Address is new
6.
12.
15,
5. Membeh Bi~date
(MMIDDrrml
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17.
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7. Membets DaytimeTelephone Number
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Patient's Name
19. Patienl's Aetna ID Number
110. Patient'sBirthdate I M w D D m
111. Patienls Reiationshi~
to Member
Self
child
PatienlsAddrpssfidiierenthrm mmbrl
113. Patient'sSex
114. Patienls Marital Slalus
Male
Female
Married
Single
118. Is claim relatedto Amencorps duties?
b claim related lo an accident?
No
Yes If yes, date
time
O a m O p m
NO
Yes
Are your expenses mvered by another group health Nan, group pre-paymentplan (Blue Cms. Blue Shield, 18. If yes, list policy or conlmcl holder, policy or contract numbeqs) end nameladdressof
insurance mmpany or adm~n~strator:
etc.), no fault auto insurance,Medicareor any fedeml,slate or local government plan?
19. To ail providers of health care:
You are authorized to provide Aetna Life insurance Company or one of its affiliated companies ("Aetna"), and any independent claim administrators and
consult~nghealth professionals and utilization review organizations with whom Aetna has contracted, informationwnceming health care advice, treatment or
.
suool~es~rovldedthe oatient fincludina that relatina to mental illness andlor AIDSIARCMIVI. This information will be used to evaluate claims for benefits.
Aetna may provide thd employer namgd above wit; any benefit calculation usea in paymeni oithls claim for the purpose of revierving the experience and
0perat:on of the policy or wntracr. Thls authorlzallon .s val~dfor the term of the policy or wntract Jnoer wnich a c alrn has been s~bm'tteo.Iknow that I nave
I a right to receive a w p y of this authorization upon request and agree that a photographic copy of this authorization is as valid as the original.
Patient's or Authorized Person's Signature
Date
20. 1 authorize payment of medical benefits to the physician or supplier of service.
Patient's or Authorized Person's Signature
Date
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TO BE COMPLETED BY PHYSICIAN OR SUPPLIER
21. Date of iiiness (first symptom)or injury (accident) or pregnancy (LMP] 22. Date firat mnsultedyou fwthis mdition 23. If patient has had similar illness or injury, give dates 24. If an emergency check
here
emergency
26. Date of total disability
27. Date of par6ai disabilii
25. Date patient able to return to work
from
through
from
through
129. For services related to hospitaliitiongive hospitaliration dates
28. Name ofrefening physician (e.g., Public HealthAgency)
I admitted
discharged
30. Name & address of facilitywhereservices rendered (if other than home or office)
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31. Diagwsisor nature of iiiness or ihjury (pleaseindicate primaryand semndary)
1.
Se~ice
IServica'
[Identify"
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ICode tt
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33. Physician'sName & Address (include dp wde)
34. Telephone Number
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38. Physidan's or Suwlieh Signature
IPlace of Service Codes:
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35. Enter lhe taxpayer identifyingnumber to be used for 1099
reparting purposes. You are required under authwity of law
to furnish your taxpayer identiwing number.
37.
39. National Pmvider idenliner
Total charge
Amount paid
Balance due
40. Date
1 (IH)
inpatient Hospital
8 (SNF) -Skilled Nursing Fadlw
2. (OH) -Outpatient Hospital
9.
Ambulaw
3 (0)
-Office Visit
0 (OL)
Olher Location
4 (H)
Palent How
A - (iL)
Independent Laboratory
5
-Day Care Fadlity (PSY)
BWler Medical Surgical Facility
6
-Night Care Facility (PSY)
C (RTC) -Residential Treatment Centw
7 (NH) -Nursing Home
D (STF) -SpecializedTreatment Facility
"Please Use Currenl Procedural Terminology Coda For Surgery
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36. PatientAcmunt Number
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$
$
$
tType of Service Codes:
1 -Medical Care
8- Assislaw at Surgely
2. Surgery
9 -Other Mediwl Serviw
3 Consullation
0. Blwd or Packed Red Cells
4 DiagnoskX-Ray
A- Used DME
5- Diagnostic Laboratmy
M. Allemale Paymenlfor Maintenance Dialysis
6 - RadiationTherapy
Y Second Opinion on Elective Surgery
7 -Anesthesia
2-Third Opinion on Eieotive Surgery
ttPlease Use ICD.9.CM For Discharge Diagnosis
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