ABCDEFGH Helpful Hints from specified disease claims department to guide you through filing your cancer, heart, stroke or accident claim with Conseco

Transcription

1 CONSECO COMPANIES ABCDEFGH Helpful Hits from specified disease claims departmet to guide you through filig your cacer, heart, stroke or accidet claim with Coseco We value you as a policyholder ad wat to make the process of filig a claim as fast ad as simple for you as possible. To assist you with the process, were providig these helpful hits: SUBMITTING A CLAIM Whe submittig a claim, attetio to the followig details will assure that the claim process moves quickly ad beefits due are processed without delay. TOP 3 REASONS CLAIMS ARE DELAYED Submit a fully completed ad siged claim form. Be sure to iclude the provider's ame, address ad phoe umber with all claims. Provide the first diagosis date for the health coditio for which bills are beig submitted. Itemized bills are required that iclude dates of service, procedure codes ad diagosis codes before beefits ca be cosidered (e.g. hospital, medical, surgical, physicia, aesthesia, etc.). Pathology reports must be submitted for all biopsies before beefits ca be cosidered. For hospital stays, completed physicia statemets are required with a diagosis for all ipatiet cofiemets alog with the correspodig itemized hospital bills before beefits ca be cosidered. For radiatio/chemotherapy beefits, a itemized bill is required showig each date of treatmet with the charges for each date before beefits ca be cosidered. For ursig home care policies, please provide the ursig home certificatio, urses liceses, ad a physicia statemet. 1. Not icludig your itemized bill 2. Not icludig your pathology report 3. Not icludig your procedure ad/or diagosis codes WHERE TO SUBMIT CLAIMS Mail all specified disease claims to: Claim Processig Coseco Compaies P.O. Box 2024 Carmel, IN Express packages should be addressed to: Att: Claim Processig 2024 Coseco Compaies N. Pesylvaia Street Carmel, IN Faxes for the health claims should be set to (317) Phoe calls may be directed to the health call ceter, (800) Please ote: Explaatio of Beefits (EOBs) from aother isurace compay caot be used to cosider beefits. The origial bills must be submitted. CDS (10/05) Coseco Marketig, L.L.C.

2 Coseco Health Isurace Compay P. O. Box 2024 Carmel, IN Telephoe ABCDEFGH CANCER, ALTERNATIVE CARE, INTENSIVE CARE AND HEART/STROKE CLAIM FORM Please fill i the policy/certificate umber(s) below that you are claimig beefits o: Cacer Alterative Care Itesive Care Heart/Stroke No. No. No. No. Ê Ê Ê FILING INSTRUCTIONS Complete PART 1, PART 2 AND PART 6 of this claim form. Please complete usig black ik. Have your attedig physicia complete the part(s) of this claim form (oly if ew or chaged diagosis or hospitalized) that correspods to the specific pla you are filig beefits uder. PART 3 - Cacer PART 4 - Itesive Care PART 5 - Heart/Stroke Cacer claims - submit a copy of the pathology report that first diagosed cacer. For subsequet surgeries, please submit the pathology report (if applicable) ad operative report, alog with correspodig bills. * Alterative Care claims - submit the itemized bills related to your cacer treatmet. Itesive Care claims - submit the itemized bill which shows the dates withi Itesive Care. Ay heart related claim or a coditio for which you were treated withi the last 12 moths, past medical history ad admit/discharge summaries may be required, (be sure to review the sectio of your policy/certificate which defies "Itesive Care Uit") Heart/Stroke claims - submit the itemized bills ad laboratory reports which treated ad/or diagosed Heart Disease, Heart Attack or Stroke. REMIT ALL BILLS, ALONG WITH THIS COMPLETED CLAIM FORM TO THE ABOVE ADDRESS - Ay icomplete portio of this claim form may result i a delay i processig your claim - CONSECO RESERVES THE RIGHT TO REQUEST ADDITIONAL INFORMATION ON ANY CLAIM FOR DETERMINATION OF BENEFITS Policyower/ Certificateholder PART 1 - POLICYOWNER/CERTIFICATE HOLDER INFORMATION Phoe Number Date of Birth Social Security # Check Here IF ew address q PART 2 - STATEMENT OF LOSS (to be completed by policyower/certificateholder) Name of Patiet Date of Birth Social Security Number Sex Male Female Relatioship to policyower/certificate holder Self Spouse So Daughter q q q q q q Describe coditio/sickess Date of first treatmet for this coditio /sickess Was this a result of a accidet? qyes qno If yes, please describe accidet If hospitalized, whe? Name ad City of Hospital List all physicias who have treated you for this coditio. Iclude Name, & Phoe Number. Name Phoe Number

3 PART 3: CANCER PHYSICIAN STATEMENT (to be completed by Physicia's Office) Physicia Name (Specialty) Phoe Number (street) (city) (state) (zip code) SECTION A: Cacer Claims (please attach copies of the pathology reports for all cacer surgeries, where applicable) Describe Coditio: Whe was ay type of cacer first diagosed? Date of first treatmet for this coditio: Type? Is this patiet's past medical history o file i your office? Please idicate the ame ad address of the referrig physicia: Was patiet totally disabled due to cacer? If yes, give dates of disability SECTION B: Hospital cofiemets Name of Hospital(s): Hospitalizatio Date(s): Diagosis treated: (ICD - 9 codes) Attach a copy of itemized bill(s) for services redered to this patiet. Physicia's Sigature: Date: PART 4: INTENSIVE CARE PHYSICIAN STATEMENT (to be completed by Physicia's Office) Physicia Name (Specialty) Phoe Number (street) (city) (state) (zip code) Dates of Itesive Care Cofiemet: Name of Hospital(s): Hospitalizatio Dates Diagosis treated: (ICD - 9 codes) Has the patiet ever had the same/similar coditio? If yes, please idicate the first date of treatmet: Has the patiet ever bee diagosed or treated for a heart attack, heart coditio, heart trouble, or ay abormality of the heart? If yes, whe ad what type? Was the cofiemet a direct result of a accidet? Was the cofiemet alcohol or drug related? If yes, was it vehicular related? If yes, please provide a copy of the laboratory results. Is this patiet's past medical history o file i your office? Please idicate the ame ad address of the referrig physicia: Attach a copy of the itemized bill(s) for services redered to this patiet. Physicia's Sigature: Date:

4 PART 5: HEART/STROKE PHYSICIAN STATEMENT (to be completed by Physicia's Office) Physicia Name (Specialty) Phoe Number (street) (city) (state) (zip code) Describe Coditio: Date of first treatmet for this coditio: Has the patiet ever bee diagosed or treated for ay of the followig coditios: Coditio Yes No Date Yes No Date Coditio Heart Attack Heart Disease Heart Abormality Disorder of Coroary Arteries Ay other Heart Coditio Arteriosclerosis High Blood Pressure Stroke If Stroke, did stroke result i paralysis? Trasiet Ischemic Attack * type of Heart Coditio Is this patiet's past medical history o file i your office? Please idicate the ame ad address of the referrig physicia: Date(s) of Hospitalizatio: Name of Hospital(s): Hospitalizatio Dates Diagosis treated (ICD - 9 codes) Attach a copy of the itemized bill(s) or laboratory reports for services redered to this patiet. Physicia's Sigature: Date: PART 6 - AUTHORIZATION I authorize ay licesed physicia, medical practitioer, pharmacist, hospital, cliic, other medical or medically related facility, federal, state or local govermet agecy, isurace or reisurig compay, cosumer reportig agecy or employer havig iformatio available as to diagosis, treatmet ad progosis with respect to ay physical or metal coditio ad/or treatmet of me, ad ay o-medical iformatio about me, to give ay ad all such iformatio to the particular compay to which I am submittig a claim, or to its legal represetative. I uderstad that the iformatio obtaied by use of this authorizatio will be used oly to evaluate my claim ad may be trasferred to ay orgaizatio or perso employed by or represetig Coseco to assist with this purpose. This authorizatio icludes iformatio about drugs, alcoholism, metal illess, sexually trasmitted disease, Huma Immuodeficiecy Virus (HIV) ad Acquired Immue Deficiecy Sydrome (AIDS). This authorizatio is valid durig the pedecy of my claim ad shall expire o the date my claim eds. I uderstad that my authorized represetative or I have the right to request ad receive a copy of this authorizatio. A photocopy of authorizatio is as valid as the origial. Failure to sig this authorizatio may impair our ability to evaluate your health claim ad may be a basis for deyig a health claim for beefits. You have the right to revoke this authorizatio by otifyig us i writig. Such revocatio may be the basis for deyig beefits. IMPORTANT Sigature Date PLEASE SIGN Z City State Zip Code

5 FRAUD WARNING: Ay perso who kowigly ad with itet to defraud ay isurace compay that submits a applicatio for isurace or statemet of claim cotaiig ay materially false iformatio, or coceals iformatio cocerig ay fact material thereto for the purpose of misleadig, may be committig a crime which is subject to crimial ad civil pealties. AK, DE RESIDENTS: A perso who kowigly ad with itet to ijure, defraud, or deceive a isurace compay files a claim cotaiig false, icomplete, or misleadig iformatio may be prosecuted uder state law. AZ RESIDENTS: For your protectio Arizoa law requires the followig statemet to appear o this form. Ay perso who kowigly presets a false or fraudulet claim for paymet of a loss is subject to crimial ad civil pealties. AR RESIDENTS: Ay perso who kowigly presets a false or fraudulet claim for paymet of a loss or beefit or kowigly presets false iformatio i a applicatio for isurace is guilty of a crime ad may be subject to fies ad cofiemet i priso. CA RESIDENTS: For your protectio Califoria law requires the followig to appear o this form: Ay perso who kowigly presets false or fraudulet claim for the paymet of a loss is guilty of a crime ad may be subject to fies ad cofiemet i state priso. CO RESIDENTS: It is ulawful to kowigly provide false, icomplete, or misleadig facts or iformatio to a isurace compay for the purpose of defraudig or attemptig to defraud the compay. Pealties may iclude imprisomet, fies, deial of isurace, ad civil damages. Ay isurace compay or aget of a isurace compay who kowigly provides false, icomplete, or misleadig facts or iformatio to a policyholder or claimat for the purpose of defraudig or attemptig to defraud the policyholder or claimat with regard to a settlemet or award payable from isurace proceeds shall be reported to the Colorado divisio of isurace withi the departmet of regulatory agecies. DC RESIDENTS: WARNING: It is a crime to provide false or misleadig iformatio to a isurer for the purpose of defraudig the isurer or ay other perso. Pealties iclude imprisomet ad/or fies. I additio, a isurer may dey isurace beefits if false iformatio materially related to a claim was provided by the applicat. FL RESIDENTS: Ay perso who kowigly ad with itet to ijure, defraud, or deceive ay isurer files a statemet of claim or a applicatio cotaiig ay false, icomplete, or misleadig iformatio is guilty of a feloy of the third degree. ID, MN RESIDENTS: Ay perso who kowigly ad with itet to defraud or deceive a isurer files a statemet of claim cotaiig ay false, icomplete, or misleadig iformatio is guilty of a feloy. IN RESIDENTS: A perso who kowigly ad with itet to defraud or deceive a isurer files a statemet of claim cotaiig false, icomplete, or misleadig iformatio commits a feloy. KY RESIDENTS: Ay perso who kowigly ad with itet to defraud ay isurace compay or other perso files a statemet of claim cotaiig ay materially false iformatio or coceals, for the purpose of misleadig, iformatio cocerig ay fact material thereto commits a fraudulet isurace act, which is a crime.

6 LA RESIDENTS: Ay perso who kowigly presets a false or fraudulet claim for paymet of a loss or beefit or kowigly presets false iformatio i a applicatio for isurace is guilty of a crime ad may be subject to fies ad cofiemet i priso. NM RESIDENTS: Ay perso who kowigly presets a false or fraudulet claim for paymet of a loss or beefit or kowigly presets false iformatio i a applicatio for isurace is guilty of a crime ad may be subject to civil fies ad crimial pealties. ME, TN, VA RESIDENTS: It is a crime to kowigly provide false, icomplete or misleadig iformatio to a isurace compay for the purpose of defraudig the compay. Pealties may iclude imprisomet, fies or a deial of isurace beefits. NH RESIDENTS: Ay perso who, with a purpose to ijure, defraud or deceive ay isurace compay, files a statemet of claim cotaiig ay false, icomplete or misleadig iformatio is subject to prosecutio ad puishmet for isurace fraud, as provided i RSA 638:20. NJ RESIDENTS: Ay perso who kowigly files a statemet of claim cotaiig ay false or misleadig iformatio is subject to crimial ad civil pealties. NY RESIDENTS: Ay perso who kowigly ad with itet to defraud ay isurace compay or other perso files a statemet of claim cotaiig ay materially false iformatio or coceals, for the purpose of misleadig, iformatio cocerig ay fact material thereto, commits a fraudulet isurace act, which is a crime ad shall also be subject to a civil pealty ot to exceed five thousad dollars ad the stated value of the claim for each such violatio. OH, OR RESIDENTS: Ay perso who, with itet to defraud or kowig that he is facilitatig a fraud agaist a isurer, submits a applicatio or files a claim cotaiig a false or deceptive statemet is guilty of isurace fraud. OK RESIDENTS: WARNING: Ay perso who kowigly, ad with itet to ijure, defraud or deceive ay isurer, makes ay claim for the proceeds of a isurace policy cotaiig ay false, icomplete or misleadig iformatio is guilty of a feloy. PA RESIDENTS: Ay perso who kowigly ad with itet to defraud ay isurace compay or other perso files a applicatio for isurace or statemet of claim cotaiig ay materially false iformatio or coceals for the purpose of misleadig, iformatio cocerig ay fact material thereto commits a fraudulet isurace act, which is a crime ad subjects such perso to crimial ad civil pealties. PR RESIDENTS: Ay perso who, kowigly ad with the itet to defraud, presets false iformatio i a isurace request form, or who presets, helps or has preseted a fraudulet claim for the paymet of a loss or other beefit, or presets more tha oe claim for the same damage or loss, will icur a feloy, ad upo covictio will be pealized for each violatio with a fie of o less tha five thousad (5,000) dollars or more tha te thousad (10,000) dollars, or imprisomet for a fixed term of three (3) years, or both pealties. If aggravated circumstaces prevail, the fixed established imprisomet may be icreased to a maximum of five (5) years; if atteuatig circumstaces prevail, it may be reduced to a miimum of two (2) years.