Fillable Instructions for Claim Submission

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Instructions for Claim Submission

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For Claims Customer Service: ( Phone: (877) 201-9373 x45704
For Claims Submission: 7 Fax: (508) 471-3208 * Email: RiderClaimsVB@trustmarkbenefits.com
Wellness / Health Screening Rider Claim Form (Rider) V08.19 Page 1
Wellness / Health Screening Rider Claim
Instructions for Claim Submission
Please be sure to review the requirements noted below for claim submission and ensure your submission is
complete to avoid any delays on your claim.
Please keep a copy of all parts of this form and any supporting documentation for your records.
Supporting Documentation
Required: Be sure to include the following required supporting documentation in your claim submission.
• Proof of testing/services you had completed, such as copies of bills, invoices, explanation of benefits,
treatment notes or test re
sults that documents:
o Date of test
o Who test completed on
o What specific test was completed
Claim Form
Required: Be sure to fully complete the following required portions of the claim form.
Incomplete or illegible answers may result in delay of benefits.
• Please complete a SEPARATE form for each individual and/or calendar year that you are claiming
benefits.
• Section A & B– To be completed by Policy Owner. Complete these sections in full and return for revie
w
of benefits.
• Claim Submission Signature – To be completed by Policy Owner. Be sure to sign and date this section of
the form
• Wellness Clinic or No Proof of Treatment – To be completed by the Medical Professional who completed
the testing. Complete this section only if services were provided through a wellness clinic OR you have
no documentation of the date and type of test provided.
Optional: These sections of the claim form are not required but completing them will provide better and faster
communication with you or anyone you designate.
• Consent for Use of Electronic Communication - To be completed by Policy Owner. Complete if you would
like claim communication by text or email, including text alerts for any payments released.
• Third Party Communication Authorization – To be completed by Policy Owner & Patient. Complete this
section if you would like to authorize Trustmark to discuss and/or release information to a third party,
including a spouse, friend or agent. Note, Policy Owner and Patient must give permission for disclosure
of their information to each other, if applicable.
Informational: These sections of the claim form provide important information about your rights and the laws in
each state.
• E-Sign Disclosure and Consent Notice - Attached for your information.
• State Required Fraud Language - Attached for your information.
A112-2506
For Claims Customer Service: ( Phone: (877) 201-9373 x45704
For Claims Submission: 7 Fax: (508) 471-3208 * Email: RiderClaimsVB@trustmarkbenefits.com
Wellness / Health Screening Rider Claim Form (Rider) V08.19 Page 2
Wellness / Health Screening Rider Claim
Section A – Policy Owner Information (To Be completed by the Policy Owner)
Policy / Certificate #: __________________
Name: ______________________________________________________ DOB: _________________ SSN: ______-______-________
Address: ____________________________________________________________________________________________________________
Street City State Zip Code
Phone #:______________________ q Home q Cell q Work E-Mail Address: _____________________________________________
Employee of Trustmark Companies?: q Yes q No Language Preference: q English q Spanish
Section B – Claim Information (To Be completed by the Policy Owner) Please complete below and attach required proof
of treatment which documents date of test, who test was completed on, and what test was completed, e.g. copies of
outpatient bills, invoice or explanation of benefits.
Name of patient: ______________________________________________ DOB: __________________ SSN: ______-______-________
Relationship to Policy Owner: q Policy Owner q Spouse q Son/Daughter q Other _____________________________
Routine Services: Please advise which routine service you had completed by providing the date it was completed in the section below.
Routine Service
Date Completed
Routine Service
Date Completed
Routine Mammogram
Heart Exercise Test or Heart Stress Test
Breast ultrasound
Stool Blood Test
Pap Smear for Women Over Age 18
Endoscopy of Lower Intestine
Colonoscopy
CA 15-3 (Blood test for breast cancer)
Fasting blood glucose test
CA125 (Blood test for ovarian cancer)
Blood test to determine Total, HDL & LDL
Cholesterol
CEA (Blood test for colon cancer)
Blood test for triglycerides
Serum Protein Electrophoresis (Blood test for
myeloma)
Prostate Specific Antigen (PSA)
Thermography
Chest X-ray
Bone marrow testing
Immunization/Routine Physicals Services: Some select accident policies include a Wellness Rider that provides coverage for two
additional services. If your accident policy includes these coverages, please complete below if you are claiming either of the following:
Service
Date Completed
Service
Date Completed
Immunization/Vaccination
Please indicate for what:
Routine Physicals
This is not a guarantee of payment. Benefits will be determined based on your policy provisions & the provisions of your
Wellness or Health Screening Rider.
Fraud Statement for the state 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.
Claim Submission Signature: Please sign, print your name and date below to certify to the accuracy of information provided.
_________________________________ ___________________
Policy Owner Signature Print Name Date
Wellness Clinic or No Proof of Treatment: This section only needs to be completed if the claimed testing was part of a
wellness clinic sponsored by your employer OR you h
ave no documentation of the date & type of test provided. To be
completed by the Medical Professional who completed the testing.
_________________________________ ____________________
Signature of Medical Professional Print Name Date
A112-2506
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For Claims Customer Service: ( Phone: (877) 201-9373 x45704
For Claims Submission: 7 Fax: (508) 471-3208 * Email: RiderClaimsVB@trustmarkbenefits.com
Wellness / Health Screening Rider Claim Form (Rider) V08.19 Page 3
Wellness / Health Screening Rider Claim
E-Sign Disclosure and Consent Notice
This E-Sign Disclosure and Consent Notice ("Notice") applies to all communications, as defined below, for
services provided by Trustmark Companies and our affiliates ("Trustmark" or "We"). Under this Notice,
communications you receive in electronic form from us will be considered "in writing."
By using Trustmark electronic and online services (“Electronic Services”), you acknowledge that your electronic
signature is legally binding and shall be treated as a valid signature for all purposes.
In addition, by using Trustmark Electronic Services you consent to the entirety of this Notice and affirm that you
have access to the hardware and software requirements identified below. You must review and accept the
terms of these services. If you choose not to consent to this Notice or you withdraw your consent, you will be
restricted from using Electronic Services.
COVERED COMMUNICATIONS
Includes, but is not limited to disclosures or communications we provide to you regarding our services such as:
(i
) claim submissions, third party authorizations, overpayment authorizations, fraud notices, terms and
conditi
ons, privacy statements or notices and any changes thereto; and (ii) customer service communications
(such as claims of error communications) ("Communications").
ME
TH
ODS OF PROVIDING COMMUNICATIONS
We may provide Communications to you by email or by making them accessible on the Trustmark websites,
mobile applications, or mobile websites (including via "hyperlinks" provided online and in e-mails).
Communications will be provided online and viewable using browser software or PDF files.
HARDWARE AND SOFTWARE REQUIREMENTS
To access and retain electronic Communications, you must have:
• A valid email address;
• A computer, mobile, tablet or similar device with internet access and current browser software and
computer software that is capable of receiving, accessing, displaying, and either printing or stori
ng
Communications received from us in electronic form;
• Su
ff
icient storage space to save Communications (whether presented online, in e-mails or PDF) or the
ability to print Communications.
We may request that you respond to an email to demonstrate you are able to receive these Communications.
HOW TO WITHDRAW YOUR CONSENT
You may withdraw your consent to receive Communications under this Notice by writing to us at "Attn: E-Sign
Disclosure and Consent Notice, 100 North Pkwy, Worcester, MA 01605." Your withdrawal of consent will cancel
your agreement to receive electronic Communications, and therefore, your ability to use our Electronic
Services.
REQUESTING PAPER COPIES OF ELECTRONIC COMMUNICATIONS
You may request a paper copy of any Communications; we will mail you a copy via U.S. Mail. To request a
paper copy, contact us by writing to "Attn: E-Sign Disclosure and Consent Notice, 100 North Pkwy, Worcester,
MA 01605." Please provide your current mailing address so we can process this request. Trustmark may charge
you a reasonable fee for this service.
A112-2506
For Claims Customer Service: ( Phone: (877) 201-9373 x45704
For Claims Submission: 7 Fax: (508) 471-3208 * Email: RiderClaimsVB@trustmarkbenefits.com
Wellness / Health Screening Rider Claim Form (Rider) V08.19 Page 4
Wellness / Health Screening Rider Claim
UPDATING YOUR CONTACT INFORMATION
It is your responsibility to keep your primary email address current so that Trustmark can communicate with you
electronically. You understand and agree that if Trustmark sends you a Communication but you do not receive
it because your primary email address on file is incorrect, out of date, blocked by your service provider, or you
are otherwise unable to receive electronic Communications, Trustmark will be deemed to have provided the
Communication to you; however, we may deem your account inactive. You may not be able to transact using
our Online Services until we receive a valid, working primary email address from you.
If you use a spam filter or similar software that blocks or re-routes emails from senders not listed in your email
address book, we recommend that you add Trustmark to your email address book so that you can receive
Communications by e-mail.
You can update your primary email address or other information by writing to us at "Attn: E-Sign Disclosure and
Consent Notice, 100 North Pkwy, Worcester, MA 01605.
FEDERAL LAW
You acknowledge and agree that your consent to electronic Communications is being provided in connection
with a transaction affecting interstate commerce that is subject to the federal Electronic Signatures in Global
and National Commerce Act, and that you and we both intend that the Act apply to the fullest extent possible
to validate our ability to conduct business with you by electronic means.
TERMINATION/ CHANGES
We reserve the right, in our sole discretion, to discontinue the provision of your Communications, or to terminate
or change the terms and conditions on which we provide Communications. We will provide you with notice of
any such termination or change as required by law.
A112-2506
For Claims Customer Service: ( Phone: (877) 201-9373 x45704
For Claims Submission: 7 Fax: (508) 471-3208 * Email: RiderClaimsVB@trustmarkbenefits.com
Wellness / Health Screening Rider Claim Form (Rider) V08.19 Page 5
Wellness / Health Screening Rider Claim
State Required Fraud Warnings
Fraud Statement for the states of Alaska, Delaware, Indiana, Kentucky, Minnesota, Ohio, and Oklahoma, as well as for all other States not
Specifically Listed: Any person who knowingly and with intent to defraud an insurer files a statement of claim containing false, incomplete
or misleading information may be guilty of insurance fraud, which is a crime.”
Fraud Statement for the state of Arizona: For your protection, Arizona law requires the
following statement 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.
Fraud Statement for the states of Arkansas, Louisiana, New Mexico, Rhode Island, Texas 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.
Fraud Statement for the state of California: For your protection, California law requires the following to appear: 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.
Fraud Statement for state 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 Policy Owner or claimant for
the purpose of defrauding or attempting to defraud the Policy Owner 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.
Fraud Statement for District of Columbia and the states of Maine, Tennessee, Virginia and Washington: 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.
Fraud Statement for the state 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.
Fraud Statement for the state of Kentucky: A 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.
Fraud Statement for the state of Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss
or benefit or 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.
Fraud Statement for the state of New Hampshire: A person who knowingly and with intent to injure, defraud or deceive an insurance
company, files a claim containing false, incomplete or misleading information may be prosecuted under state law.
Fraud Statement for the state of 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 Statement for the state of Oregon: Any person who knowingly and with intent to defraud an insurer files a statement of claim
containing materially false or misleading information may be guilty of insurance fraud.
Fraud Statement for the state of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other
person files any 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.
A112-2506
For Claims Customer Service: ( Phone: (877) 201-9373 x45704
For Claims Submission: 7 Fax: (508) 471-3208 * Email: RiderClaimsVB@trustmarkbenefits.com
Wellness / Health Screening Rider Claim Form (Rider) V08.19 Page 6
Wellness / Health Screening Rider Claim
Consent for Use of Electronic Communications
(EMAIL, SMS/MMS TEXT MESSAGING)
To ensure the best and fastest communication, we would like to communicate with you using either email or
text messaging. Please complete this section if we may communicate with you electronically, concerning your
claim, benefits, policy, premium or condition.
May we communicate with you electronically?
q No
q Yes, by Text Messages - Please provide cell phone #: (_____) - ______ - ______
q Yes, by Email Please provide email address: _____________________________________@ ___________________
If you chose to communicate with us electronically, you should be aware that electronic communication is not
secure unless it is encrypted. We strongly encourage you to use encrypted communication when sending
sensitive and/or confidential information. By sending sensitive or confidential electronic messages that are not
encrypted, you accept the risks of such lack of security and possible lack of confidentiality. If you elect to
communicate from your workplace computer, you should also be aware that your employer and its agents,
have access to electronic communication between you and us.
I understand that by selecting text messaging, regular text messaging rates may apply for any texts I receive
from Trustmark and I assume responsibility for any costs associated with these text messages. This consent shall
remain in effect unless revoked by notifying Trustmark.
To ensure a smooth email experience, please be sure that your computer has the most up to date version of
Adobe Reader. You should add our email address to your address book contact list and add us to your email
server or spam filter approved listing. If you don’t see email from us in your email inbox, be sure to check your
spam, clutter, junk or bulk email folder. You can choose to stop electronic communication at any time by
revoking this authorization. If you no longer wish to communicate via electronic means we will correspond with
you via US mail. If you require copies of any communication sent to you by email/text in paper form, please
contact us. There is no cost to you to obtain copies of electronic communication in paper format.
Should you prefer to submit your claims or claims information by U.S. Mail rather than email or fax, please use
the following address: Trustmark Insurance PO Box 2906, Clinton, IA 52733
Authorization
I may revoke or update this authorization at any time by notifying Trustmark.
This authorization is valid for 24 months. I may request a copy of this authorization and a copy is as valid as the
original.
Policy Owner Signature Date
Printed Name Social Security Number
A112-2506
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For Claims Customer Service: ( Phone: (877) 201-9373 x45704
For Claims Submission: 7 Fax: (508) 471-3208 * Email: RiderClaimsVB@trustmarkbenefits.com
Wellness / Health Screening Rider Claim Form (Rider) V08.19 Page 7
Wellness / Health Screening Rider Claim
Third Party Communication Authorization
Please complete this authorization if you would like us to discuss, to release, or to provide information to a third
party regarding any policy and/or claim for benefits under your policy. Note: Policy Owner and Claimant (if
appropriate) must give permission for disclosure of their information to each other, if applicable.
Policy Owner Name: ________ SSN: _______
Claimant Name (if appropriate): ____________________________________________________________________
Policy Number(s): _______________ _____________________
Name & Relationship of Third Party Representative:
□ All information (all policy and claim information)
□ Only the following information*: ___________________________________________________
Name & Relationship of Third Party Representative:
□ All information (all policy and claim information)
□ Only the following information*: ___________________________________________________
□ My Agent: (Name of Agent) ____________________________________________________________
□ All information (all policy and claim information)
□ Only the following information*: ________________________________________________
□ My Employer: (Name of Agent) ________________________________________________________
□ All information (all policy and claim information)
□ Only the following information*: ________________________________________________
*Restrictions may include a restriction on certain types of information (such as not sharing financial, medical or health
information).
I agree that if I authorize release of all policy and/or claim information this may include health information
which may be related to disorders of the immune system including but not limited to HIV and AIDS, use of
alcohol or drugs, mental and physical condition, history, or treatment.
I understand that any information shared may be subject to re-disclosure and might not be protected by
certain federal or state regulations governing the privacy of health information relative to my condition.
I may revoke and update this authorization in writing at any time or by email to address noted above. I
understand that this authorization is valid until my revocation or until I complete a new authorization. Any new
authorization will effectively revoke this authorization and replace it.
_________________________________________ _________________________________________
Signature of Policy Owner Signature of Claimant
(If someone other than the Policy Owner)
_________________________________________ _________________________________________
Printed Name
________________
Date
Printed Name
________________
Date
A112-2506
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Instructions for Claim Submission

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Completed 30 March 2021

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