School Accident Program Parent/Guardian Guide Program 3

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Eunice Russell
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1 School Accident Program Parent/Guardian Guide Program 3 A nonprofit independent licensee of the BlueCross BlueShield Association

2 Dear Parent or Guardian: This packet contains important documents regarding benefits provided to you by your child s school district and Excellus BlueCross and BlueShield. Please retain these documents in your files of other important matters. We encourage you to familiarize yourself with the benefit, instructions and forms in this packet. If you have any questions, please contact our Customer Service Department at (585) or toll-free at Thank you.

3 School Accident Program Q & A What is the School Accident Program (SAP)? Your School District has contracted with Excellus BlueCross BlueShield to provide coverage for an accidental injury suffered by each student during school, on the way to or from school, and during school sponsored and supervised activities. Who is eligible for SAP? All students enrolled in a school district which offers the School Accident Program. What happens when an accident or injury occurs? After an accident occurs, the student must check in with the school office, nurse or other school personnel to make sure the accident is reported. The school will complete Section I of the Excellus Notice of Pupil Injury (NPI) Form. The school will then forward the NPI Form to the parent or guardian to complete and sign Section II. Where should I send the Notice of Pupil Form? Please complete, sign and mail within 10 business days from the date of injury. Mail to: Attention: SAP Department Excellus BlueCross BlueShield P.O. Box Rochester, NY *We must have the NPI form on file in order to process any claims under the School Accident Program. When do I file a claim to SAP? All medical claims should be submitted to the student s medical plan first then to SAP with an Explanation of Benefits. If the student has coverage through a government plan such as Child Health Plus or Medicaid, claims should be submitted to SAP first. All claims related to an accidental injury to a sound and natural tooth should be submitted to the students medical plan first then to their dental plan (if applicable). Submit any remaining balances to SAP with an itemized bill and Explanation of Benefits from both the medical and dental plans. *See Program Overview regarding deferred dental treatment. How do I file a claim? Complete and submit a SAP Claim form, Itemized bill, an Explanation of Benefits from your medical insurance (if applicable) An Itemized bill must include: Name and address (on letterhead) of the provider of service or supply (hospital, doctor, pharmacy, etc.). Patient's full name. Type of service or supply (office visits, chest x-ray, etc.). Place of service (inpatient or outpatient hospital, office, etc.). Please contact servicing provider for valid Health Care Service Codes (HCSC). Date and charge for each service that was rendered or supplies provided. Patient's diagnosis (the medical condition for which the patient was treated). *We cannot accept receipts, cancelled checks, co-payment amounts or statements of balances due. If you have any questions related to the School Accident Plan please call our Customer Services Department at: (585) or A nonprofit independent licensee of the BlueCross BlueShield Association

4 School Accident Program Overview Program 3 GENERAL INFORMATION Your school district has contracted with Excellus BlueCross BlueShield to provide coverage up to $15,000 for accidental injury suffered by each student during school, on the way to or from school, and during school-sponsored and supervised activities, including athletics. This overview summarizes benefits, eligibility, non-covered services and claim filing procedures. The terms contained in the master contract, issued to the school district, are binding. If you have any questions you may call our Customer Service Department at (585) or toll-free at 1-(800) BENEFITS (Initial services must be rendered within 30 days of the accident.) Hospital Care Full coverage is provided for semi-private room and all other customary services for up to 120 days, and for care rendered in outpatient and emergency departments. Physician s Care Surgery, anesthesia, and in-hospital medical visits are covered according to rates stipulated in the Blue Shield Schedule of Allowances. Physician s Care - In the Home or Office Full coverage, up to the usual and customary charge, for physician s home or office visits. Dental Treatment Full coverage, up to the usual and customary charge for accidental injury to sound, natural teeth. In the event of deferred treatment, payment will be based on the approved allowance at the time of the accident to treat no more than two teeth. Payment for deferred treatment will be made at the time the services are actually rendered, even if the insured no longer has coverage through Excellus BlueCross BlueShield. The Dental Provider must submit a Deferred Treatment plan to Excellus BlueCross BlueShield within 1 year from the date of injury. X-ray Examinations You are covered for X-ray examinations within 90 days of the accident. Private Duty Nursing Payment is made for private duty registered nurses (RN) when ordered by the attending physician and when the patient s condition warrants this level of treatment. Prescription Drugs You are covered for prescription drugs ordered by the attending physician. Ambulance Service Partial coverage to or from the hospital is included in this contract. CLAIMS AND PAYMENT PROCEDURES If the injured student has other coverage through a parent or guardian, please ask the servicing provider to submit to that plan or insurance company first. Any remaining balances can be submitted to SAP for consideration. If the student has coverage through a government plan such as Child Health Plus or Medicaid, claims should be submitted to the Student Accident Program first. All claims related to an accidental injury to a sound and natural tooth should be submitted to the students medical plan first then to their dental insurance (if applicable). Submit any remaining balances to SAP with an itemized bill and Explanation of Benefits from both the medical and dental plans. In order to process claims, we must have a Notice of Pupil Injury on file. Your child s school will send you a form to complete shortly after the injury occurs. If you do not receive the form within 5 days, please contact the school directly. You will need to complete Section II of the NPI form and sign. Once completed mail to: Attention: SAP Department Excellus BlueCross BlueShield P.O Box Rochester, New York Be sure the proper school authority, usually the school nurse, has been notified of the accident..

5 Right to Review If you do not agree with a claim determination, please call our Customer Service Department after you receive your Explanation of Benefits. Our Customer Service Representative will help you with the process. EXPLANATION OF COORDINATION OF BENEFITS The School Accident Policy was designed to assist in covering expenses resulting from accidental injury to any student. We are able to offer this program at a reasonable cost only by coordinating the benefits of your School Accident Policy with those of any other contract or policy which you might hold. The purpose of Coordination of Benefits (COB) is to hold down the cost of health insurance. It is applied when a patient has two or more group coverages for the same medical service. COB assures the subscriber of the full protection which those coverages provide, but eliminates double payments for the same services. If the student qualifies for coverage under another contract or policy, all claims must be processed first against that policy (or policies). This includes the regular family Blue Cross and Blue Shield contracts, but does not include Medicaid. The School Accident Policy will provide some payment for covered services (up to the maximum) in accordance with the benefits listed. Any service for which the student is covered under any other contract or policy, or under any governmental program, excluding Medicaid. Any person enrolled under an adult education program. Injections, supplies or crutches Services rendered more than a year from the date of an accident. Claims for physician s services submitted more than a year from the date of service. Physician s charges for "clinic visits, "billed by the hospital. NOT COVERED Eyeglasses, contact lenses or prescriptions for glasses or lenses. Treatment by any person employed or retained by the school. Injuries covered by Workers Compensation or similar legislation. Any injury occurring while operating or riding in or on any two-or-three wheeled motor-driven vehicle. Any benefits when mandatory automobile no-fault insurance benefits are recovered or recoverable for the same service. Any injury resulting from air travel unless the member is a passenger on a regularly scheduled flight of a licensed commercial airline going directly to, or returning directly from, a school-sponsored function. Any injury sustained while participating in or traveling to or from any summer vacation activity unless activity is school-sponsored and educational in nature.

6 SCHOOL ACCIDENT PROGRAM A nonprofit independent licensee of the BlueCross BlueShield Association SAP Claim Form Mail Completed Claims To: Attention: SAP Department Excellus BlueCross BlueShield PO Box Rochester, NY Parent/ Guardian Name Address School Accident Program Identification Number: SAP 1. Student Information: Student's Full Name: City, State, Zip Code Sex: Male Female School District Name / School Name: Student's Date of Birth: (mm/dd/yyyy) If your address has changed or is incorrect, please call our Customer Service Department as instructed on the back of the form. Student Diagnosis: Date of Injury: (mm/dd/yyyy) 2. Check if you want payment to be made directly to the provider..... (Payment will not be made directly to non participating providers.) 3. Motor Vehicle or Work Related Illness or Injury: a. Was the treatment in any way motor vehicle related? If yes to question (a.) please provide the following information: No Fault Carrier Name: YES NO No Fault Carrier Case Number: b. Was the treatment a result of a work related illness or injury? If yes to question (b.) please provide the following information: Workman's Compensation Carrier Name: YES NO Workman's Compensation Case Number: 4. Claim Date and Parent/Guardian Signature: (Unsigned claims will be returned.) Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals information concerning any fact material thereto, for the purpose of misleading, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each violation. In addition, I hereby authorize any insurance company, organization, employer, hospital, doctor or any other provider of service to release any information requested relevant to this claim and any attached bills. Date: Parent/Guardian's Signature: MSA-52 08/07

7 How To Submit Your Claim This claim form can be used to submit all your bills. However, a separate claim form must be completed for each person's bills. If you need additional claim forms or if you have any questions about completing the claim form or benefits covered under your contract, please contact Customer Service at: local (585) or toll free Visit us at Mail completed claims to: Attention: SAP Department Excellus BlueCross BlueShield PO Box Rochester, NY In order to process your claim promptly, please refer to the following guidelines to ensure that all necessary information is included: A. All medical claims should be submitted to the students medical plan first then to SAP with an Explanation of Benefits. B. All claims related to an accidental injury to a sound and natural tooth should be submitted to the students medical plan first then to their dental Insurance (if applicable). Submit any remaining balances to SAP with Explanation of Benefits from both the medical and dental plans. C. Submit bills for each patient on separate claim forms. A separate claim form is also required for different calendar years. Please submit the original bills with your claim form. Keep copies for your own records. The actual bills are necessary for claims processing. D. Bills must include: Name and address (on letterhead) of the provider of service or supply (hospital, doctor, pharmacy, etc.). Patient's full name. Type of service or supply (office visits, chest x-ray, etc.). Place of service (inpatient or outpatient hospital, office, etc.). Please contact servicing provider for valid Health Care Service Codes (HCSC). Date and charge for each service that was rendered or supplies provided. Patient's diagnosis (the medical condition for which the patient was treated). E. Cash register receipts, canceled checks, money orders, credit card vouchers and personal lists of services or bills stating only 'balance forward' are not acceptable as substitutes for bills. F. Bills for the following services should also include: FOR THOSE CONTRACTS WITH PRESCRIPTION DRUG COVERAGE - Prescription number, name of drug, and name of prescribing doctor is required. Private Duty Nurse - The type of Nurse (RN or LPN), license number, the shift and hours worked. A statement of medical necessity from the prescribing doctor. Durable Medical Equipment (wheelchair, oxygen tank, etc.) - A statement of medical necessity from the prescribing doctor which indicates how long the equipment will be used and a statement from the equipment supplier showing both the rental and purchase price. Our employees are dedicated to prompt and accurate claim payments to our subscribers. By following these instructions and filling out the claim form completely, you will help us meet our goal of processing your claim in a satisfactory manner.

8 K /07

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