SHORT-TERM HOME HEALTH CARE CLAIM FORM

Transcription

1 SHORT-TERM HOME HEALTH CARE CLAIM FORM Please ead the impotant infomation below: Please be sue you policy numbe(s) is/ae witten on all documents. The claim fom must be completed and signed by the Insued o esponsible paty. Please attach Powe of Attoney o Guadian papes if applicable. The HIPAA Authoization to Pemit Use and Disclosue of Health Infomation must be signed, dated and included with you submission, so that we can contact you medical povide on you behalf if additional infomation is needed. Attach itemized bills (we don t pay advanced billings) to the claim fom. Fo faste pocessing, please be sue you answe ALL questions on the claim fom. Include Aide note(s). An itemized bill is a statement that indicates: 1. The date(s) of teatment, 2. The type(s) of sevice, 3. The diagnosis, 4. The medical povide s name and addess, 5. The individual chage fo each expense. Pocessing delays may esult if you do not povide all the above infomation. Please send all infomation to: Guaantee Tust Life Insuance P.O. Box 1144 Glenview, Illinois OR Fax to: (847) If you policy has been in foce less than two yeas fom when you diagnosis was made, a completed claim fom, and signed authoization needs to be submitted with you initial claim (pe medical condition). If you policy has been in foce moe than two yeas fom when you diagnosis was made, a claim fom is not equied, unless equested by us. NOTE: You Policy may have a Pe-Existing Conditions Limitation and a 2 Yea Policy Contestability Peiod. If you claim happened duing one of these peiods, additional infomation may be equied. If we need to equest any additional infomation and we have you signed HIPAA Authoization, we will handle these equests diectly with you medical povide(s) and will notify you of ou action and any delays. If you signed a benefits assignment with the povide and you have a balance still due, we ae equied to pay that balance diectly to them; othewise, benefits will be sent to you. Attach Physician s Home Health Cetification (Fom PHHC). We suggest you make photocopies of any infomation sent fo you own ecods. Fo assistance, please contact ou Custome Sevice Depatment (800) STCF 02/17

2 Mail claims to: P.O. Box 1144 Glenview, Illinois O fax to: (847) Fo Custome Sevice, please call: (800) SHORT-TERM HOME HEALTH CARE CLAIM FORM TO BE COMPLETED BY THE INSURED Policy Numbe(s) Policyholde s Name Claimant/Patient Name Date of Bith Addess (Steet) (City) (State) (Zip Code) Phone TYPE OF BENEFIT(S) FOR WHICH THE CLAIM IS BEING MADE Skilled Nusing Cae (RN) Geneal Nusing Cae (LPN/LVN) Physical Theapy Speech Pathology Occupational Theapy Chemotheapy Specialist Enteostomal Theapy Respiational Theapy Medical Social Sevices Date symptoms fist appeaed: Date of fist visit with physician? Date of actual/definitive diagnosis: Have you eve had this illness/condition befoe? Yes No If yes, date? If yes, what s the name, addess and telephone numbe of physician? If hospitalized fo this illness/condition, what s the name and addess of hospital/medical cente? Pimay Cae (family docto) name, addess and telephone numbe: Whee thee any othe physicians seen duing the last two (2) yeas? (if moe space is needed, please attach sepaate sheet) If so, please povide thei names, addesses and phone numbes: Physician name, addess and phone numbe Physician name, addess and phone numbe Physician name, addess and phone numbe Page 2 STCF 02/17

3 PHYSICIAN S HOME HEALTH CERTIFICATION Mail claims to: P.O. Box 1144 Glenview, Illinois O fax to: (847) Fo Custome Sevice, please call: (800) Policy No. Patient s Name and Addess Cetification Peiod Fom: 1. Physician s Name and Addess To: Date of Bith: Sex: M F 2. Physician s Tax I.D. No. 3. ICD-10-CM Pincipal Diagnosis Date 5. Pio Hospital Confinement fo which Subsequent Home Health Cae was needed: 4. ICD-10-CM Othe Petinent Diagnosis Date A. Fom: To: B. Name of Hospital and Addess 6. Can the patient pefom any of the following Activities of Daily Living (ADL s) without the assistance of anothe peson? YES NO A. Bathing (getting in and out of the bathtub o showe, utilizing nomal bathoom facilities that have been equipped with ailings and steps); B. Continence (bladde contol); C. Dessing (tying shoes, buttoning buttons o clasps); D. Eating (consuming food o dink o utilizing utensils, appopiate fo the patient s physical condition and which ae placed within each); E. Toileting (maintaining adequate bathoom hygiene and toilet habits); o F. Tansfeing to o fom bed o chai If any of the above ae answeed NO, please funish test esults. 7. Does the patient equie continuous supevision and assistance due to a Cognitive Impaiment (a deficiency in the ability to think, peceive, eason, and/o emembe, which has been evaluated and measued though clinical evidence and standadized tests)? YES NO If YES, please funish test esults. 8. Home health sevices pefomed: Skilled Nusing (Skilled nusing cae povided by a egisteed nuse (RN)) Geneal Nusing (Geneal nusing cae povided by a licensed pactical nuse (LPN) o licensed vocational nuse (LVN)) Physical Theapy Speech Pathology Occupational Theapy Chemotheapy Specialist Sevices Enteostomal Theapy Respiation Theapy Medical Social Sevices Home Health Cae Aide (any individual, othe than a membe of the patient s immediate family, woking unde the supevision of an RN, who is qualified, by taining and expeience, to povide assistance with the Activities of Daily Living listed in 6 above and has been cetified by the appopiate egulatoy authoity). Othe (specify) 9. Othe Remaks: 10. I cetify ecetify that the above statements ae tue and coect and ae based on standad medical tests I have pefomed and that the above home health sevices wee/ae equied duing the peiod of cetification. 11. Cetifying Physician s Signatue Date Signed PHHC 05/17

4 Guaantee Tust Life Insuance Company P.O Box 1144, Glenview, Illinois HIPAA AUTHORIZATION To Pemit Use and Disclosue of Health Infomation This Authoization was pepaed by GTL fo puposes of obtaining infomation necessay to pocess a claim fo benefits. Policy/Cetificate # Upon pesentation of the oiginal o a photocopy of this signed Authoization, I authoize, without estiction (except psychotheapy notes), any licensed physician, medical pofessional, hospital o othe medical-cae institution, insuance suppot oganization, phamacy, govenmental agency, insuance company, goup policyholde, employe o benefit plan administato to povide Guaantee Tust Life Insuance Company (GTL) o an agent, attoney, consume epoting agency o independent administato, acting on it s behalf, all infomation concening advice, cae o teatment povided the patient, employee o deceased named below, including all infomation elating to, mental illness, use of dugs o use of alcohol. This Authoization also includes infomation povided to ou health division fo undewiting o claim sevicing and infomation povided to any affiliated insuance company on pevious applications. If this Authoization is fo someone othe than myself, that individual and my authoity to act on thei behalf is explained below. I undestand that I o my authoized epesentative is entitled to eceive a copy of the Authoization upon equest. I undestand that I have the ight to evoke this Authoization, in witing, at any time by sending witten notification to my (ou) agent o to the Company at the above addess. I undestand that a evocation will not be effective to the extent the Company has elied on the use o disclosue of the potected health infomation o if my Authoization was obtained as a condition to detemine my eligibility fo benefits. Revocation equests must be sent in witing to the attention of the Claim Depatment Manage. I undestand that Guaantee Tust Life Insuance Company may condition payment of a claim upon my signing this Authoization, if the disclosue of infomation is necessay to detemine the level o validity of the claim payment. I also undestand once infomation is disclosed to us pusuant to this Authoization, the infomation will emain potected by GTL in accodance with fedeal o state law. This authoization shall emain in foce and in effect until two (2) yeas fom the date this authoization is signed at which time this authoization will expie. (Pint Please) Name of Patient Date of Bith Signatue of Patient Date (Please Pint) Name of Authoized Repesentative, o Next of Kin Relationship of Authoized Repesentative o Next of Kin to Patient Signatue of Authoized Repesentative o Next of Kin Date AUTH15-01 CLAIM (A) 07/15

5 Dea Insued: Below is a listing of the faud language that you State Depatment of Insuance equies us to give to you. Please fist locate you state of esidence and then ead the faud language that petains to you state. Thank you. Connecticut Geogia Hawaii Iowa Illinois Kansas Massachusetts Michigan Missoui Mississippi Montana Nebaska Noth Caolina Noth Dakota Nevada South Caolina South Dakota Utah Vemont Wisconsin Wyoming Geneal Faud Waning (to be used fo above states only) Any peson who knowingly pesents a faudulent claim containing any false o misleading infomation is guilty of insuance faud and may be subject to fines and confinement in pison. Alabama Any peson who knowingly pesents a false o faudulent claim fo payment of a loss o benefit o who knowingly pesents false infomation in an application fo insuance is guilty of a cime and may be subject to estitution, fines, o confinement in pison, o any combination theeof. Alaska A peson who knowingly and with intent to injue, defaud, o deceive an insuance company files a claim containing false, incomplete, o misleading infomation may be posecuted unde state law. Aizona - Fo you potection Aizona law equies the following statement to appea on this fom. Any peson who knowingly pesents a false o faudulent claim fo payment of a loss is subject to ciminal and civil penalties. Akansas, Louisiana, Rhode Island and West Viginia Any peson who knowingly pesents a false o faudulent claim fo payment of a loss o benefit o knowingly pesents false infomation in an application fo insuance is guilty of a cime and may be subject to fines and confinement in pison. Califonia Fo you potection Califonia law equies the following to appea on this fom: Any peson who knowingly pesents false o faudulent claim fo the payment of a loss is guilty of a cime and may be subject to fines and confinement in state pison. Coloado It is unlawful to knowingly povide false, incomplete, o misleading facts o infomation to an insuance company fo the pupose of defauding o attempting to defaud the company. Penalties may include impisonment, fines, denial of insuance and civil damages. Any insuance company o agent of an insuance company who knowingly povides false, incomplete, o misleading facts o infomation to a policyholde o claimant fo the pupose of defauding o attempting to defaud the policyholde o claimant with egad to a settlement o awad payable fom insuance poceeds shall be epoted to the Coloado Division of Insuance within the depatment of egulatoy agencies. Delawae Any peson who knowingly, and with intent to injue, defaud o deceive any insue, files a statement of claim containing any false, incomplete, o misleading infomation is guilty of a felony. Distict of Columbia WARNING: It is a cime to povide false o misleading infomation to an insue fo the pupose of defauding the insue o any othe peson. Penalties include impisonment and/ o fines. In addition, an insue may deny insuance benefits if false infomation mateially elated to a claim was povided by the applicant. Floida Any peson who knowingly and with intent to injue, defaud o deceive any insuance company files a statement of claim o an application containing any false, incomplete, o misleading infomation is guilty of a felony of the thid degee. Idaho Any peson who knowingly, and with intent to defaud o deceive any insuance company, files a statement containing any false, incomplete, o misleading infomation is guilty of a felony. Indiana A peson who knowingly and with intent to defaud an insue files a statement of claim containing any false, incomplete, o misleading infomation commits a felony. Faud 12-16

6 Kentucky A peson who knowingly and with intent to defaud any insuance company o othe peson files a statement of claim containing any mateially false infomation o conceals, fo the pupose of misleading, infomation concening any fact mateial theeto commits a faudulent insuance act, which is a cime. Maine It is a cime to knowingly povide false, incomplete, o misleading infomation to an insuance company fo the pupose of defauding the company. Penalties may include impisonment, fines, o a denial of insuance benefits. Mayland Any peson who knowingly and willfully pesents a false o faudulent claim fo payment of a loss o benefit o who knowingly and willfully pesents false infomation in an application fo insuance is guilty of a cime and may be subject to fines and confinement in pison. Minnesota A peson who files a claim with intent to defaud o helps commit a faud against an insue is guilty of a cime. New Hampshie Any peson who, with a pupose to injue, defaud o deceive any insuance company, files a statement of claim containing any false, incomplete o misleading infomation is subject to posecution and punishment fo insuance faud, as povided in RSA 638:20. New Jesey Any peson who knowingly files a statement of claim containing any false o misleading infomation is subject to ciminal and civil penalties. Ohio and Oegon Any peson who, with intent to defaud o knowing that he is facilitating a faud against an insue, submits an application o files a claim containing a false o deceptive statement is guilty of insuance faud. Oklahoma WARNING: Any peson who knowingly, and with intent to injue, defaud o deceive any insue, makes any claim fo the poceeds of an insuance policy containing any false, incomplete o misleading infomation is guilty of a felony. Pennsylvania Any peson who knowingly and with intent to defaud any insuance company o othe peson files statement of claim containing any mateially false infomation o conceals fo the pupose of misleading, infomation concening any fact mateial theeto commits a faudulent insuance act, which is a cime and subjects such peson to ciminal and civil penalties. Tennessee, Viginia and Washington State It is a cime to knowingly povide false, incomplete, o misleading infomation to an insuance company fo the pupose of defauding the company. Penalties include impisonment, fines, and denial of insuance benefits. Texas Any peson who knowingly pesents a false o faudulent claim fo the payment of a loss is guilty of a cime and may be subject to fines and confinement in state pison. New Mexico ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. Faud 12-16