Fillable Benextend Claim Form

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Benextend Claim Form

On average this form takes 33 minutes to complete

The Benextend Claim Form form is 6 pages long and contains:

  • 1 signature
  • 77 check-boxes
  • 93 other fields

Country of origin: US
File type: PDF

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BENEXTEND CLAIM FORM INSTRUCTIONS
To avoid delays in processing of your claim form, complete each section attaching documentation below when it applies.
Supporting Documentation Needed
Itemized bill if there was a hospital stay (UB04 from the hospital or medical facility)
Chart Note to include admission and discharge paperwork if there was a hospital stay
Itemized bill from physician’s office (HCFA 1500 from treating physician’s office)
Surgical Report if surgery took place
Xray/Diagnostic Tests-receipts with dates and charges if applicable
Accident Report-if applicable (ex: police report)
Benefit Assignment-Benefits are payable to the policy holder unless written authorization is received from you or
your healthcare provider to assign benefits to the provider. If you choose to assign benefits, attach a signed and
written request.
Email form to groupclaimfiling@aflac.com
or fax to 1.866.849.2970.
BENEXTEND CLAIM FORM
AUTHORIZAT IO N
Several states require that the follow ing statement appear on claim forms: Any person w ho know ingly attempts to def raud any insurance
company, files a statement of claim containing any materially false, incomplete or misleading information, is guilty of a crime.
I hereby certify that the answ ers I have made to the foregoing questions are both complete and true to the best of my know ledge and
belief. I have read the fraud notice included in this f orm.
Policyholder’s signature: Date:
Patient’s Signature: Date:
POLICYHOLDER/PATIENT INFORMATION
Employer’s Name
Policyholder’s Email Address
Policyholder’s Name
Policy No
Social Security No
Date of Birth
Gender
Policyholder’s Telephone No. (w ith area code)
Patient’s Name (Person w ho is sick or
injured)
Patient’s Date of Birth
Patient’s Gender
Relationship to Policyholder
*By providing your e-mail address above, you consent to the use of electronic transactions in connection with your CAIC policies, contracts, and/or accounts
to the extent available permitted by law (which may include, but not
limited to: invoices, claim correspondence, contracts, surveys, and other materials that
CAIC is, or may be, legally required to deliver to you).
Please sign the attached HIPAA form and return it w ith the completed claim form.
*****If f iling a claim w ithin the f irst policy year f or benefits, medical records may be requested*****
Is medical treatment due to an injury? If yes, provide the date of the injury.
No Yes
Describe how the injury occurred.
Location of the injury: On the job Off the job
If injury w as on the job, has a Worker’s Compensation claim been filed?
No Yes
If yes, w hat is the status of the Worker’s Compensation claim? Approved Pending Denied
Was the patient injured in a motor vehicle accident?
No Yes
(If yes, attach a copy of the police report.)
Is treatment related to an illness? No Yes
(If yes, complete the follow ing questions related to illness.)
What is the first date of treatment for the illness?
What is the illness diagnosis?
Did the accident or illness result in death
? No Yes ( If yes, attach a copy of the death certificate.)
If diagnosed w ith cancer, w hat is the date of the initial diagnosis? (Attach a copy of the pathology report.)
Cancer; Carcinoma in situ; Skin Cancer: Please submit a copy of the pathology report from w hich the condition w as diagnosed.
Stroke: Please submit a copy of the discharge s ummar y , MRI and/or CT test reports from the initial diagnosis, as w ell as proof of
permanent neurological damage (i.e. f ollow up CT and/or MRI reports, office notes from neurologist or therapist, etc.)
Major Organ Transplant; Bone Marrow Transplant: Please submit a copy of the operative report for the procedure.
Heart Attack; Sudden Cardiac Arrest: Please submit a copy of the discharge s umma r y , cardiology consult report, cardiac
catheterization report, history & physical, and ER notes.
Renal Failure: Please submit proof of the start date for dialysis or the operative report for transplant. The End Stage Renal Disease
Medical Evidence Report is preferred.
Heart Event: Please submit a copy of the operative report for the procedure.
Occupational HIV (if applicable)
Coronary Artery Bypass Surgery: Please submit a copy of the operative report for the procedure.
Non-invasive cancer
Skin Cancer (Must submit pathology report.)
click to sign
signature
click to edit
PREGNA NC Y CLAIM S
Date of Delivery
Type of Delivery
Vagin a l Caesa re a n
If not delivered, expected delivery date:
Date of last menstrual period?
List any compl ic at i on s relate d to your preg na n cy.
COMPLETE THIS SECTION FOR ALL CLAIMS.
Patient’s primary treating physician.
Physician Name:
Address:
City, State, Zip
Phone:
Was the patient confined to the hospital as a result of this condition?
No Yes
(If confined, please submit copy of patient’s admission and discharge papers or a copy of a UB-04 billing invoice from the hospital.)
Hospital/Facility Name:
Phone:
Admission Date:
Discharge Date:
Was the patient transported by an ambulance as a result of this injury? No Yes
(If yes, attach the ambulance bill.)
Was the patient confined to the intensive care unit as a result of this condition?
No Yes
(If yes, submit copy of a UB-04 billing invoice from the hospital facility to identify the days spent in the intensive care unit.)
Was the patient treated in an emergency room as a result of this condition?
No Yes
(If yes, submit emergency room admission and discharge papers.)
Was surgery performed as a result of the medical condition?
No Yes
(If yes, submit a copy of the operative report.)
0B
Was an aid in locomotion (mobility) prescribed as a result of this injury? (ie: Crutches, Wheelchairs, Leg Braces, Walking Boots, Back
Braces, Walkers, Cervical Collars) No Yes
1B
(If yes, submit documentation from the prescribing provider.)
2B
Was a major diagnostic exam (ie: CT Scan, MRI, MRA, EEG) performed as a result of this condition? No Yes
3B
(If yes, please submit a copy of the exam report of billing.)
HAVE THE FOLLOWING SECTIONS COM PLETED BY THE PHYSICIAN WHEN FILING FOR CRITICAL ILLNESS BENEFITS
ATT ENDING PHYSICIAN’S STAT EM ENT
Patient’s name:
Date of birth:
When did signs and/or symptoms first
appear?
Has the patient ever received medical
advice or treatment for this or a similar
condition?
No Yes, when
Diagnosis (including complications)
Cancer/ carcinoma in situ
Date of diagnosis (the date the pathological specimen(s) w ere obtained on w hich cancer
or carcinoma in situ w ere diagnosed)
Was the cancer/carcinoma in situ:
Diagnosed pathologically
Clinically diagnosed
If the cancer/carcinoma in situ w as pathologically diagnosed, attach a copy of the pathology report. If the cancer/carcinoma in situ w as
clinically diagnosed, please provide the reason(s) that pathological diagnosis w as not obtained and attach medical evidence that supports
the diagnosis of cancer.
MYOCARDIAL INFARCTION (HEART ATTACK)
Does the patient’s condition meet all of the f ollow ing criteria:
Are new and serial electrocardiographic (ekg) findings consistent w ith myocardial infarction? Yes No
(If yes, attach a copy of the ekgs and report.)
Yes No
W
ere cardiac enzymes elevated above generally accepted laboratory levels of normal for
creatine physphokinase
(cpk), a cpk-mb measurement mus t be used?
( If yes, attach a copy of the lab report.)
Yes No
Did diagnostic studies confirm a myocardial infarction and the occlusion of one or more coronary arteries?
(Attach copies of any applicable reports.)
Yes No
Did the patient have chest pain consistent w ith myocardial infarction?
Date of diagnosis: (the date the patient met all of the above criteria for myocardial infarction)
4B
CORONARY ARTERY BYPASS SURGERY
5BYes No
6BDid the patient undergo open heart surgery to correct narrowing or blockage of one or more coronary arteries with bypass
grafts? If so, attach a copy of the operative report.
7B
What condition caused the need for coronary artery bypass surgery?
8B
Date the patient was first treated for signs or symptoms of this condition?
9B
MAJOR ORGAN TRANSPLANT
10BYes No
11BDid the patient undergo surgery to receive a human heart, liver, lung, kidney pancreas or bone marrow? If so, attach copy of
the operative report.
12B
Date the patient was first treated for signs or symptoms of this condition?
13B
STROKE
14BY e s No
15BDid the patient have a stroke, meaning apoplexy, secondary to rupture or acute occlusion of a cerebral artery? Stroke does
not include transient ischemic attacks and attacks of verterbrobasilar ischemia, head injury, or chronic cerebrovascular
insufficiency.
16B
Date of diagnosis (the date a stroke occurred based on documented neurological deficits and neuroimaging studies?
17B
RENAL FAILURE
18BYes No
19BD
oes the patient have end stage renal failure presenting as chronic, irreversible failure to function of both kidneys?
20BY e s No
21B
Does the patient’s kidney failure necessitate regular renal dialysis, hemo-dialysis or peritoneal dialysis (at least weekly) or
which results in kidney transplantation?
22BDate of diagnosis (The date a doctor or physician recommends that the
patient begin renal dialysis.)
23BDate the patient first treated for signs or symptoms of this condition?
24BWhat is the cause for the patient’s renal disease?
25B
PHYSICIAN’S STATEMENT
26B
Is the patient unable to perform job duties? No Yes If yes, please provide dates:
27B
What specific job duties is the patient unable to perform?
28B
Restrictions and limitation: (Please quantify in hours, weight, etc.)
29B
If retired or unemployed which activities of daily living (ADLs) is patient unable to perform?
30BIs the patient:
31BAmbulatory
32BBed Confined
33BHouse Confined
34BWas the patient hospitalized or confined to a skilled nursing facility? No Yes
If yes, provide hospital address:
Date of Admission:
Date of Discharge:
Date you expect patient to resume partial duties:
Date you expect patient to resume full duties:
35B
If patient is unemployed or retired, on what date would you expect a person of like age, gender and good health to resume his/her normal and necessary
activities?
36BWas the patient treated by any other physician’s for this condition? No Yes
If yes, provide name and addresses of other treating physicians:
37BRemember, it is unlawful to fill out this form with facts you know are false or to leave out facts you know are relevant and important. Check to be sure that all
information is correct before signing. Please refer to page 3 for notice specific to your state.
I hereby certify that the above described information is based upon reasonable medical probability and is true and correct to the best of my knowledge and
belief.
38B
ATTENDING PHYSICIAN’S INFORMATION AND SIGNATURE
39BI hereby certify that the above described information is based upon reasonable medical probability and is true and correct to the best of my knowledge and
belief.
40B
Name (Please print.):
41B
Degree:
42B
Telephone Number:
43B
Address:
44B
City:
45B
State:
46B
Zip Code:
47B
Signature:
48B
Date
49B
Medical Id#
AUTHORIZATION TO OBTAIN INFORMATION
MAIL TO: Continental American Insurance Company
P.O. Box 84075
Columbus, Georgia 31993
CALL: 1.800.433.3036 (toll-f ree)
CLAIM FAX: 1.866.849.2970
Primary Certificateholder’s Na me: SSN(optional): Date of Birth:
Certificate Number(s):
Ad dre ss:
Name of Individual Subject to Disclosure (If not the primary Certificateholder): Date of Birth:
Relationship to Primary Certificateholder:
Self Spouse Domestic Partner Child Stepchild Grandchild
I.
Authorization:
For the purpose of evaluating my eligibility for insurance and for benefits under an existing certificate, including checking
for and resolving any issues that may arise regarding incomplete or incorrect information on my application for coverage
and/or claim form, I hereby authorize the disclosure of the following information(defined below) about me and, if
applicable, my dependents, from the sources listed below to Continental American Insurance Company (CAIC), or any
person or entity acting on its part, to include American Family Life Assurance Company of Columbus and American
Family Life Assurance Company of New York (collectively, “Aflac).
II.
Di scl osure of Health Information:
Health information may be disclosed by any health care provider, health plan (including CAIC or Aflac, with respect to other
CAIC or Aflac coverages) or health care clearinghouse that has any records or knowledge about me. Health care provider
includes, but is not limited to, any licensed physician, medical or nurse practitioner, nurse, pharmacist, osteopath,
psychologist, physical or occupational therapist, chiropractor, dentist, audiologist or speech pathologist, podiatrist, hospital,
medical clinic or laboratory, pharmacy, rehabilitation facility, nursing home or extended care facility, prescription drug
database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be
disclosed by any insurance company or the Medical Information Bureau (MIB). Health information includes my entire
medical record, but does not include psychotherapy notes. Some information obtained may not be protected by certain
federal regulations governing the privacy of health information, but the information is protected by state privacy laws and
other applicable laws. CAIC will not disclose the information unless permitted or required by those laws.
III.
Rights and Expiration:
I understand that I may revoke this authorization at any time, except to the extent that CAIC or Aflac has taken action in
reliance on this authorization. If I revoke this authorization, CAIC may not be able to evaluate my application for coverage
and/or claim. To revoke this authorization, I must provide a written and signed revocation to CAIC at the address or fax
number above. Unless otherwise revoked, this authorization shall remain in effect for two (2) years from the date signed
or upon my death, whichever occurs first. I agree that a copy of this authorization is as valid as the original and that I or an
authorized representative may request a copy of this authorization.
I V.
Notice:
I understand that CAIC is not conditioning payment, enrollment, or eligibility for benefits on whether I sign this
authorization. I understand that if the information disclosed is protected health information relating to a health plan and the
person or entity receiving the information is a not a health care provider or health plan covered by federal privacy
regulations, the information disclosed may be redisclosed by such person or entity and will likely no longer be protected
by the federal privacy regulations.
•
If records are on an a dul t dependent, (e.g. spouse, child over 18), the dependent m ust si gn this form
•
If records are on a m i nor child the natural parent or le gal guardian m ust si gn on their be half.
Signature of Individual Subject to Disclosure Date Signed
Legal Representative’s Printed Name Legal Representative’s Signature Legal Relationship
If signed by a legal representative (e.g. Legal Guardian, Estate Administrator, Power of Attorney)
AGC06105
Date Signed
Electronic Funds Transaction Authorization
Send to: Continental American Insurance Company
Post Office Box 84075
Columbus, Georgia 31993
Phone: (800) 433-3036 Fax (866) 849-2970
Email: groupclaimfiling@aflac.com
Authorization Agreement for Direct Deposit
I would like to: ☐ Start ☐Stop ☐Change direc t deposit of my claim payment(s).
Account Type:
Checking Savings
**** Please provide a blank voided check or
direct deposit form from your financial
institution. Incomplete or inaccurate
information will not be processed.
9-Digit Routing Number:
Account Number:
Name of Financ ial Institution:
Address:
City:
State:
Zip:
Phone:
I authorize Continental American Insuranc e Company (CAIC) to initiate c redit entries, and, if errors occ ur, I
authorize the correction of entries to my account as indicated. T his authorization remains effective and in full force
until C AI C receives written notification from m e of its termination in s uc h time and in such manner to afford CAIC a
reasonable opportunity to act on it. Please notify CAIC immediately if your financ ial institution information has
changed by sending notific ation to the address indic ated above. Should you have any questions, please contact us at
1-800-433-3036.
Polic y/Certific ate Holder’s Name (Print):
Address:
City/State/Zip:
Phone #:
E-mail Address:
Employer Name or Group #:
Certific ate #:
***By providing your e-ma i l address above, you consent to the use of electronic transactions in connection with your CA IC policies, contracts, and/or
accounts to the extent available and permitted by law (which ma y i n cl ud e, but not limited to: invoices, claim correspondence, contracts, surveys, and
other materials that CAIC is, or may be, legally required to deliver to yo u)
Note: Forms received without signature will not be processed. Electronic signatures not accepted.
Policy/Certificate Holder Signature (Required) Date Signed:
Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a w
holly-owned subsidiary of Aflac Incorporated and underwrites group coverage. Aflac is
not licensed to solicit
business in New York, Guam, Puerto Rico, or the Virgin Islands. For groups sitused in California, coverage is undewritten by Continental American Life Insurance Company. For groups
sitused in New York, coverage is underwritten by American Family Life Assurance Company of New York.
Continental American Insurance Company • 1600 Williams St • Columbia, South Carolina 29201 • 1-800-433-3036 toll-free • 1-866-849-2970 fax
FRAUD WARNING NOTICES
For use with Claim Forms
PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
ALASKA: A person who knowingly and with intent to injury,
defraud or deceive an insurance company files a claim
containing false, incomplete, or misleading information may be
prosecuted under state law.
IDAHO: Any person who knowingly, and with intent to defraud
or deceive any insurance company, files a statement of claim
containing any false, incomplete, or misleading information is
guilty of a felony.
ARIZONA: For your protection Arizona law requires the
following statement to appear on this form. Any person who
knowingly presents a false or fraudulent claim for payment of a
loss is subject to criminal and civil penalties.
INDIANA: A person who knowingly and with intent to defraud
an insurer files a statement of claim containing Any false,
incomplete, or misleading information commits a felony.
ARKANSAS: 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 fines and confinement
in prison.
KENTUCKY: 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, for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent
insurance act, which is a crime.
CALIFORNIA: For your protection California law requires the
following to appear on this form:
Any person who knowingly presents a false or fraudulent claim
for the payment of a loss is guilty of a crime and may be subject
to fines and confinement in state prison.
LOUISIANA: 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 fines and confinement
in prison.
COLORADO: It is unlawful to knowingly provide false,
incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to
defraud the company. Penalties may include imprisonment,
fines, denial of insurance and civil damages. Any insurance
company or agent of an insurance company who knowingly
provides false, incomplete, or misleading facts or information
to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard
to a settlement or award payable from insurance proceeds
shall be reported to the Colorado division of insurance within
the department of regulatory agencies.
MAINE: It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the
purpose of defrauding the company. Penalties may include
imprisonment, fines or a denial of insurance benefits.
MARYLAND: Any person who knowingly and willfully presents
a false or fraudulent claim for payment of a loss or benefit or
who knowingly and willfully presents false information in an
application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
DELAWARE: Any person who knowingly, and with intent to
injure, defraud or deceive any insurer, files a statement of
claim containing any false, incomplete or misleading
information is guilty of a felony.
MINNESOTA: A person who files a claim with intent to defraud
or helps commit a fraud against an insurer is guilt of a crime.
DISTRICT OF COLUMBIA: WARNING: It is a crime to provide
false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include
imprisonment and/or fines. In addition, an insurer may deny
insurance benefits if false information materially related to a
claim was provided by the applicant.
NEW HAMPSHIRE: Any person who, with a purpose to injure,
defraud, or deceive any insurance company, files a statement
of claim containing any false, incomplete, or misleading
information is subject to prosecution and punishment for
insurance fraud, as provided in RSA 638:20.
FLORIDA: Any person who knowingly and with intent to injure,
defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading
information is guilty of a felony of the third degree.
NEW JERSEY: Any person who knowingly files a statement of
claim containing any false or misleading information is subject
to criminal and civil penalties.
FRAUD WARNING NOTICES (CONT.)
For use with Claim Forms
PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
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.
TENNESSEE: It is a crime to knowingly provide false,
incomplete or misleading information to an insurance c om p any
for the purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.
NEW YORK: Any person who knowingly and with intent to
defraud any insurance company or other person files an
application for insurance or statement of claim containing any
materially false information, or conceals for the purpose of
misleading, information concerning any fact material
thereto, commits a fraudulent insurance act, which is a crime,
and shall also be subject to a civil penalty not to exceed five
thousand dollars and the stated value of the claim for each
such violation.
TEXAS: Any person who knowingly presents a false or
fraudulent claim for the payment of a loss is guilty of a crime
and may be subject to fines and confinement in state prison.
OHIO: Any person who, with intent to defraud or knowing that
he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive
statement is guilty of insurance fraud.
VIRGINIA: It is a crime to knowingly provide false, incomplete
or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.
OKLAHOMA: WARNING: Any person who knowingly, and with
intent to injure, defraud or deceive any insurer, makes any claim
for the proceeds of an insurance policy containing any false,
incomplete or misleading information is guilty of a felony.
WASHINGTON: It is a crime to knowingly provide false,
incomplete, or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines, and denial of insurance
benefits.
OREGON: Any person who, with intent to defraud or knowing
that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive
statement may be guilty of insurance fraud.
RHODE ISLAND and WEST VIRGINIA: 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 fines and confinement in prison.
PENNSYLVANIA: Any person who knowingly and with intent to
defraud any insurance company or other person files an
application for insurance or statement of claim containing any
materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties.
ALL OTHER STATES: Any person who knowingly and with
intent to defraud any insurance company or other person
files an application for insurance or statement of claim
containing any materially false information or conceals for the
purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is
a crime and subjects such person to criminal and civil
penalties.
PUERTO RICO: Any person who knowingly and with the
intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of a loss
or any other benefit, or presents more than one claim for the
same damage or loss, shall incur a felony and, upon
conviction, shall be sanct
ioned for each violation with the
penalty of a fine of not less than five thousand dollars ($5,000)
and not more than ten thousand dollars ($10,000), or a fixed
term of imprisonment for three (3) years, or both penalties.
Should aggravating circumstances are present, the penalty
thus established may be increased to a maximum of five (5)
years, if extenuating circumstances are present, it may be
reduced to a minimum of two (2) years.
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Benextend Claim Form

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Completed 2 July 2020

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