CONSECO COMPANIES Helpful Hits From the Claims Departmet to guide you through filig your Welless Beefit claim We value you as a customer 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, we re providig these helpful hits: SUBMITTING A CLAIM Whe submittig a claim, attetio to the followig details will assure that your claim moves quickly ad beefits due are processed without delay. Submit a fully completed ad siged claim form. Be sure to iclude the provider s ame, address ad phoe umber with all claims. This claim form is desiged specifically for the welless beefit that was purchased as part of your policy. If you eed to submit claim for a beefit other tha the welless beefit, please submit a claim form for your policy type to our office for cosideratio. If your policy provides oe mammogram beefit per caledar year, please mark the appropriate box ad idicate the date the mammogram was performed. Please check your policy for specific beefits covered uder your policy. TOP REASONS CLAIMS MAY BE DELAYED 1. Policy or certificate umber is ot show o the claim form ad/or supportig documets. WHERE TO SUBMIT CLAIMS Mail all welless beefit claims to: Claim Processig Coseco Compaies P.O. Box 2024 Carmel, IN 46082 Express packages should be addressed to: Att: Claim Processig 2024 Coseco Compaies 11825 N. Pesylvaia Street Carmel, IN 46032 Faxes for the health claims should be set to (317) 208-8656. Phoe calls may be directed to customer service at (800) 824-2726. Please ote: Explaatio of Beefits (EOBs) from aother isurace compay caot be used to support your claim. Copies of the origial bills must be submitted. Phoe: (800) 541-2254 Fax: (317) 208-8656 *WCF01*
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WELLNESS BENEFIT CLAIM FORM Failure to complete all sectios may result i a delay i processig this claim. This form ca be used for the followig compaies: Coseco Isurace Compay Coseco Life Isurace Compay Coseco Health Isurace Compay Washigto Natioal Isurace Compay Some of the tests listed may ot be covered uder the Welless Beefit of your policy. Please check your policy for a list of covered welless procedures. Please complete this form i its etirety. Keep copies of the supportig documetatio ad this completed form for your records. Sig, date, ad mail the completed form to the Coseco address show below. POLICY OR CERTIFICATE NUMBER POLICYHOLDER S FIRST NAME: POLICYHOLDER INFORMATION MIDDLE INITIAL: POLICYHOLDER S LAST NAME: POLICYHOLDER S BIRTH DATE: POLICYHOLDER S ADDRESS: FIRST NAME: PATIENT INFORMATION MIDDLE INITIAL: LAST NAME: RELATIONSHIP: Q Primary Policyholder Q Spouse Q Depedet Child DATE OF BIRTH: SEX: Q Male Q Female WELLNESS EXAM Welless Exam Date: Q Colooscopy Q Hemocult stool specime Q Flexible sigmoidoscopy Q Virtual colooscopy Q CEA (blood test for colo cacer Q Thermography Q Pap smear ThiPrep Q CA 125 (blood test for ovaria cacer) Q Chest X-ray Q Pap smear Q Mammogram Q PSA (blood test for prostate cacer) Q Breast ultrasoud/soogram Q Biopsy Q Other Pap Smear Date: Mammogram Date: Mammogram Cost: NAME: PHYSICIAN INFORMATION POLICY NUMBER: ADDRESS: CITY: STATE: ZIP: By sigig my ame o this documet, I declare that all of the iformatio give is true ad correct to the best of my kowledge ad belief. I ackowledge I have received all required fraud warigs at the time of executig this form. PATIENT S SIGNATURE (or legal represetative) RELATIONSHIP DATE OWNER S SIGNATURE (or legal represetative) DATE *WCF03*
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For your protectio, the laws of several states require the followig statemet: Fraud Warig: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. AK, Residets: 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 Residets: 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 Residets: 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 Residets: 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 Residets: 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. DE Residets: Ay perso who kowigly, ad with itet to ijure, defraud or deceive ay isurer, files a statemet of claim cotaiig ay false, icomplete, or misleadig iformatio is guilty of a feloy. DC Residets: 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 Residets: 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 Residets: Ay perso who kowigly, ad with itet to defraud, or deceive ay isurace compay, files a statemet of claim cotaiig ay false, icomplete, or misleadig iformatio is guilty of a feloy. IN Residets: A perso who kowigly ad with itet to defraud a isurer files a statemet of claim cotaiig ay false, icomplete, or misleadig iformatio commits a feloy. KY Residets: 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. LA Residets: 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. ME Residets: 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. MN Residets: A perso who files a claim with the itet to defraud or helps commit a fraud agaist a isurer is guilty of a crime. NH Residets: 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 638:20. NJ Residets: Ay perso who kowigly files a statemet of claim cotaiig ay false or misleadig iformatio is subject to crimial ad civil pealties. NM Residets: 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. *WCF05*
NY Residets: Ay perso who kowigly ad with itet to defraud ay isurace compay or other perso files a applicatio of 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 shall also be subject to a civil pealty ot to exceed five thousad dollars ad the stated value of the claim for such violatio. OH Residets: 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 Residets: 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. OR Residets: 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 may be guilty of isurace fraud. PA Residets: 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 Residets: Ay perso who kowigly ad with the itetio of defraudig presets false iformatio i a isurace applicatio, or presets, helps, or causes the presetatio of a fraudulet claim for the paymet of a loss or ay other beefit, or presets more tha oe claim for the same damage or loss, shall icur a feloy ad, upo covictio, shall be sactioed for each violatio with the pealty of a fie of ot less tha five thousad dollars ($5,000) ad ot more tha te thousad dollars ($10,000), or a fixed term of imprisomet for three (3) years, or both pealties. Should aggravatig circumstaces are preset, the pealty thus established may be icreased to a maximum of five (5) years, if exteuatig circumstaces are preset, it may be reduced to a miimum of two (2) years. RI Residets: 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. TN Residets: It is a crime to kowigly provide false, icomplete or misleadig iformatio to a isurace compay for the purpose of defraudig the compay. Pealties iclude imprisomet, fies ad deial of isurace beefits. RI Residets: Ay perso who kowigly presets a false or fraudulet claim for the paymet of a loss is guilty of a crime ad may be subject to fies ad cofiemet i priso. VA Residets: It is a crime to kowigly provide false, icomplete or misleadig iformatio to a isurace compay for the purpose of defraudig the compay. Pealties iclude imprisomet, fies ad deial of isurace beefits. WA Residets: It is a crime to kowigly provide false, icomplete or misleadig iformatio to a isurace compay for the purpose of defraudig the compay. Pealties iclude imprisomet, fies ad deial of isurace beefits. WV Residets: 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. *WCF06*
Authorizatio to Release Iformatio Health Isurace Claims Processig--pursuat to the HIPAA Privacy Rule l. My iformatio - the idividual whose iformatio will be released Name: Date of Birth: Policy Number: Address: ll. Disclosig Party - orgaizatio authorized to release my iformatio Ay physicia or other health care provider, hospital, cliic, medical facility, cliical lab, pharmacy or pharmacy-related orgaizatio, health pla or isurace compay lll. Descriptio of my iformatio authorized for release Ay iformatio related to my past, preset or future medical care or treatmet (icludig metal health, commuicable disease, HIV/AIDS ad substace abuse records, but excludig psychotherapy otes), uless specifically limited by me as follows:. lv. Purpose of release - describig how my iformatio will be used by the Receivig Party after it is released Processig my health isurace claim(s) V. Duratio of authorizatio This authorizatio will expire 24 moths from the date writte below, uless I specify a alterate expiratio date here: Vl. Receivig Party - orgaizatio that will receive my iformatio Coseco, Ic. ad its affiliated isurace compaies (Coseco Isurace Compay, Coseco Health Isurace Compay, Coseco Life Isurace Compay, Washigto Natioal Isurace Compay, Bakers Life ad Casualty Compay, Bakers Coseco Life Isurace Compay ad Coloial Pe Life Isurace Compay) Vll. Approval - Siged ad dated by me or my legal represetative I uderstad that I ca revoke this authorizatio at ay time, except to the extet it has already bee relied upo, by sedig a writte revocatio to: CONSECO CLAIMS DEPT PO BOX 2024 CARMEL, IN 46082-2024 I uderstad that my treatmet, paymet ad eligibility for beefits may ot be coditioed o this authorizatio I uderstad that if the perso or orgaizatio I authorize to receive the iformatio described above is ot subject to federal health iformatio privacy laws, it could be re-disclosed ad o loger protected by federal health iformatio privacy laws. I uderstad that I am etitled to a copy of this authorizatio, ad that a photocopy or facsimile is as valid as the origial. Prit Name: Sigature: * Legal Represetatives provide documetatio of legal authority Relatioship: Date: Vlll. Retur siged ad dated form *WCF07*