How to file a Medical Claim
(For Special Risk, Sports, Campers, Youth Groups, and Participant Accident Insurance Policies)
Attached is a claim form for your accident policy.
Please forward claims and questions to the following address:
MCA Administrators, Inc
PO Box 6540
Harrisburg, Pa 17112
Ph: 1-800-427-9308
Fax: (717) 652-8328
Email: Student-insurance@mcoa.com
Step 1: The Participating Organization (NOT the Parent, Claimant or Agent) should:
Fully answer each item in Part I, The Participating Organization Statement.
Read the fraud warning statement on page 3 and sign the form where indicated in Part I.
Step 2: The Parent/Guardian or Adult Claimant Should:
Fully answer each item in Part II, including the claimant’s personal information, parent’s
information, along with other insurance information.
In order to ensure we receive complete claim information, we require providers to submit
standardized billing statements (called “UB04” for hospital charges and/or a “CMS-1500” for
physician charges).
Providers may bill us directly. If they do, please ensure a completed claim form has first been
submitted to our office.
If other insurance exists, include the other insurance company’s corresponding Explanation of
Benefits (EOBs). We are Primary over State provided (i.e. Medicaid, Gateway, etc.)
Insurance and Non-active Duty TRICARE.
Unless proof of payment is submitted with the medical bill (a copy of the check, a medical bill
that indicates the claimant has made all or partial payment, or zero balance information) claim
payment is generally sent directly to the medical providers.
Review Part III, Authorizations
Read the fraud warning statement on page 3 and sign where indicated on the bottom of the Claim
Form.
Helpful information for submitting claims
A fully completed Claim Form is required for each accident/injury. Claims submitted with
incomplete information will be sent back to injured party, to complete missing information.
The acceptance of a claim form by an insurance company is not an admission of coverage.
The claimant must seek treatment, resulting in a medical expense, within 30/60/90 days of the
injury. Contact our office for verification.
Written proof of loss must be furnished to the Company within 90 days after the date of the
Covered Loss or as soon as reasonably possible and in no event, except in the absence of legal
capacity of the claimant, later than one year from the time proof is otherwise required.
Step 3: Submit the Completed Notice of Claim (Claim Form) via either by mail, fax, or email listed
above. Please note: if sending information via email, it is only used to receive incoming
information. Any questions about claims please call our office.
AXIS 6/2019
1. Please Fully Complete This Form
2. See Filing Instructions Attached
3. Mail To
Policy Number: Organization Name: Event, Activity, or Sport:
Claimant's Name (Injured Person) The Injured Person Was A: Date And Time Of Accident:
Participant Staff Member Other
Place Where Accident Occurred: Type Of Injury: (Indicate Part Of Body Injured - e.g. broken arm, etc.)
Describe How Accident Occurred - Provide All Possible Details:
Dental Indicate Which Teeth Were Involved: Describe Condition Of Injured Teeth Prior To Accident:
Claims Whole, Sound & Natural Filled Capped Artificial
Did Accident (Check Yes Or No For Each Of The Following):
A. During A Participating Organization Sponsored & Supervised, or Sanctioned Activity? YES No
B. On Activity Premises: YES No
C. While Traveling Directly And Uninterruptedly To Or Form The Activity? YES No
D. During A Participating Organization Practice Or Competition? YES No
E. Did Injury Result In Death: YES No
Signature Of Participating Organization Representative: Name & Title Of Participating Organization Representative: Date:
Best Contact Number (Included Area Code): Social Security Number (Of Injured): Gender (Of Injured): Date Of Birth (Of Injured):
M
F
Address (in which information should be mailed to):
Do you/spouse/parent have medical/health care, or are you enrolled as an individual, employee or dependent member of a Health Maintenance
Organization (HMO) or similar prepaid health care plan, or any other type of accident/health/sickness plan coverage through an employer, a
parent's employer, or other source? YES No
If yes, name of insurance company: _________________________________________________ Policy #: __________________________
Are you eligible to receive benefits under any governmental plan or program, including Medicare? YES No
If yes, please explain: ________________________________________________________________________________________________
Mother (Guardian's) primary employer name, address & telephone: ________________________________________________________________
Father (Guardian's) primary employer name, address & telephone: ________________________________________________________________
I authorize medical payments to physician or supplier for services described on any attached statements. If not signed, provide proof of payment.
SIGNATURE: ________________________________________________________________________ DATE: ____________________________
I authorize any physician, medical professional, hospital, covered entity as defined under HIPPA, insurer or other organization or person having
any records, dates or information concerning the claimant to disclose when requested to do so, all information with respect to any injury, policy
coverage, medical history, consultation, prescription or treatment, and copies of all hospital or medical records or all such records in their
entirety to AXIS Insurance Company or its designated administrator. A photo static copy of this authorization shall be considered as effective
and valid as the original.
I agree that should it be determined at a later date there is other insurance (or similar), to reimburse AXIS Insurance Company to the extent of
any amount collectible. I understand that any person who knowingly and with the intent to defraud or deceive any insurance company; files a
claim containing any material by false, incomplete, or misleading information, may be subjected to prosecution for insurance fraud.
SIGNATURE:
DATE:
____________________________
PART I - PARTICIPATING ORGANIZATION STATEMENT
PART II - PARENT, RESPONSIBLE PARTY, OR GUARDIAN STATEMENT
PART III - AUTHORIZATIONS
Fax: 717-652-8328
Email: student-insurance@mcoa.com
MCA Administrators, Inc
PO Box 6540
Harrisburg, PA 17112
Phone: 1-800-427-9308
AXIS 6/2019
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AXIS 06-2019
FRAUD STATEMENTS
____________________________________________________________________________________________________________________________
Important Notice
In General, and specifically for residents of Arkansas, Louisiana, 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.
For residents of 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.
For residents of the 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.
For residents of 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.
For residents of Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance 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.
For residents of Maine, Tennessee, Virginia and 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.
For residents of Maryland and Oregon: 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.
For residents of New Jersey: Any person who includes any false or misleading information on an application for an
insurance policy is subject to criminal and civil penalties.
For residents of 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.
For residents of 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.
For residents of 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.
For residents of 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.
For residents of 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.
AXIS 6/2019