Fill - Free fillable How to file a Medical Claim (All Risks, Ltd) PDF form

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):

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

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