Fillable NGL Student Accident Packet (Hastings College)

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NGL Student Accident Packet (Hastings College)

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In order to receive benefits based on the School’s Student Accident Policy, all medical bills must be first
submitted to the student’s own health insurance carrier providing the student’s primary medical coverage.
Student Accident Insurance is intended to be a supplemental coverage to your primary carrier’s coverage, there-
fore, benefits will not be paid for medical expenses covered by your own health insurance.
When we are the secondary plan, we do not pay until after the primary plan has paid its benefits if any. We will
review Usual & Reasonable charges of each plan and allow the highest. Any amount paid by your primary plan for
an eligible expense under our plan may satisfy all or a portion of our deductible.
Student Accident Insurance is administered by Commercial Travelers Life Insurance Company. In order to claim
expenses not covered by your primary health insurance, the following steps must be followed:
• School Official completes the Student Accident Report.
• Submitting the appropriate documentation is essential for timely adjudication of your claim expenses.
Please note: If you are receiving treatment from a provider (primary care physician), please request a CMS
1500 (see attached example). If you are receiving treatment from a hospital, please request a UB04 (see
attached example).
• Please submit any Notice of Payment or Rejection (explanation of benefits—EOB) forms from your primary
health insurance carrier. Any itemized billing statements submitted must include a diagnosis code and
procedure code.
• Please notify all physicians, hospitals and any other healthcare providers that have or will be treating you
and provide them the insurance information about the school’s accident insurance carrier. Please ask the
providers to bill the claims administrator as secondary insurance at the following address:
Commercial Travelers Life Insurance Company
Attn: Claim Administration
70 Genesee Street
Utica NY 13502
Fax No. 315-797-0195
claims@commercialtravelers.com
Should you have any questions or concerns regarding your coverage or claim, please call the claims administrator,
Commercial Travelers Life Insurance Company at 1-800-756-3702.
Administered by:
ACF 2018(ACC) 1
Plan Administered by:
For Toll-free Policyholder Service 1-800-756-3702 • Utica area 315-797-5200
Underwritten by:
NATIONAL GUARDIAN LIFE INSURANCE COMPANY
Student Accident Report
School Report
Name of College or University Policy #
Name of Student Male Female
First Middle Initial Last
Student School Address
Street City State Zip
Student Home Address
Street City State Zip
Date of Birth Email Address
Cell Phone No. Social Security No. Student ID No.
Place of Accident Accident Date
Circumstance: Game Practice Conditioning Other Type of Injury:
Club Sport Intramural
Intercollegiate Non-athletic
Body Part Injured Name of Sport (if Athletic)
Nature of — Details of What Happened
Treated or referred by the Student Health Center Yes No Date of treatment or referral
Name of School Official or Coach Supervising the Activity
INSURANCE INFORMATION
Does the claimant have primary insurance? Yes No (Attach separate sheet if necessary.)
Insurance Company Name & Address
Policy Number ID No.
I hereby certify that I have read the answers to all parts of this form and to the best of my knowledge and belief the information
is complete and correct as given herein.
Any person who includes any false or misleading information on an application or statement of claim for an insurance policy is
subject to criminal and civil penalties.
Signature of School Official/Title Date Signed
70 GENESEE STREET
UTICA, NEW YORK 13502
Instructions
1. Form must be completed by a school official/athletic director.
2. Include copies of itemized bills that include a diagnosis.
3. Include copies of Explanation of Benefits statements from your
Primary insurance carrier—one for each bill.
4. Later itemized bills and Explanation of Benefit statements can be
mailed separately. Make sure the name of the student is on all
correspondence.
5. If you have submitted an accident report to another insurance
company, please attach a copy.
6. Save copies of submitted materials for your records.
CLICK HERE TO
RESET FORM
ACF 2018(ACC) 2
AK, CT, DE, HI, IA, ID, IL, IN, MI, MN, MO, MT, MS, NC, ND, NV, SC, SD, UT, WI & WY: Any person who knowingly and with intent to defraud an insurer
submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.
AL, AR, DC, LA, MA, and RI: 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.
AZ: 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.
CA: 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.
CO: 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.”
FL: 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.
GA, NE, KS, OR, TX, VT: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially
false or misleading information may be guilty of insurance fraud.
KY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any mate-
rially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,
which is a crime.
ME: 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.
MD: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NH: 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.
NJ: Any person who includes any false or misleading information on an application or statement of claim for an insurance policy is subject to criminal and
civil penalties.
NM: 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.
NY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for health insurance or statement of
claim containing any materially false information, or conceals for the purpose of misleading, any 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 $5,000.00 and the stated value of the claim for each
such violation.
OH: 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.
PA: 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 fraudu-
lent insurance act, which is a crime and subjects such person to criminal and civil penalties.
OK: 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.
TN: 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.
VA, WA: 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 or a denial of insurance benefits.
WV: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an appli-
cation for insurance is guilty of a crime and may be subject to fines and confinement in prison.
1a. INSURED’S I.D. NUMBER (FOR PROGRAM IN ITEM 1)
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
7. INSURED’S ADDRESS (No., Street)
CITY STATE
ZIP CODE TELEPHONE (INCLUDE AREA CODE)
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. INSURED’S DATE OF BIRTH
b. EMPLOYER’S NAME OR SCHOOL NAME
c. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
payment of medical benefits to the undersigned physician or supplier for
services described below.
SEX
F
HEALTH INSURANCE CLAIM FORM
OTHER
1. MEDICARE MEDICAID CHAMPUS CHAMPVA
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE
I authorize the release of any medical or other information necessary
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
below.
SIGNED DATE
ILLNESS (First symptom) OR
INJURY (Accident) OR
PREGNANCY(LMP)
MM DD YY
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE
MM DD YY
14. DATE OF CURRENT:
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
19. RESERVED FOR LOCAL USE
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
17a. I.D. NUMBER OF REFERRING PHYSICIAN
From
MM DD YY
To
MM DD YY
1
2
3
4
5
6
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?
(For govt. claims, see back)
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
SIGNED DATE
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
RENDERED (If other than home or office)
SIGNED
MM DD YY
FROM TO
FROM TO
MM DD YY
MM DD YY
MM DD YY
MM DD YY
CODE ORIGINAL REF. NO.
$ CHARGES EMG
COB
RESERVED FOR
LOCAL USE
28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
$$$
33. PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE
& PHONE #
PIN# GRP#
PICA
PICA
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
5. PATIENT’S ADDRESS (No., Street)
CITY STATE
ZIP CODE TELEPHONE (Include Area Code)
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
a. OTHER INSURED’S POLICY OR GROUP NUMBER
b. OTHER INSURED’S DATE OF BIRTH
c. EMPLOYER’S NAME OR SCHOOL NAME
d. INSURANCE PLAN NAME OR PROGRAM NAME
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
YES NO
( )
If yes
, return to and complete item 9 a-d.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
20. OUTSIDE LAB? $ CHARGES
22. MEDICAID RESUBMISSION
23. PRIOR AUTHORIZATION NUMBER
MM DD YY
CARRIER
PATIENT AND INSURED INFORMATION
PHYSICIAN OR SUPPLIER INFORMATION
M
F
YES NO
YES NO
1. 3.
2. 4.
DATE(S) OF SERVICE
Type
of
Service
Place
of
Service
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS MODIFIER
DIAGNOSIS
CODE
PLEASE
DO NOT
STAPLE
IN THIS
AREA
F
M
SEX
MM DD YY
YES NO
YES NO
YES NO
PLACE (State)
GROUP
HEALTH PLAN
FECA
BLK LUNG
Single Married Other
3. PATIENT’S BIRTH DATE
6. PATIENT RELATIONSHIP TO INSURED
8. PATIENT STATUS
10. IS PATIENT’S CONDITION RELATED TO:
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
b. AUTO ACCIDENT?
c. OTHER ACCIDENT?
10d. RESERVED FOR LOCAL USE
Employed Full-Time Part-Time
Student Student
Self Spouse Child Other
(Medicare #) (Medicaid #) (Sponsor’s SSN) (VA File #) (SSN or ID) (SSN) (ID)
( )
M
SEX
DAYS
OR
UNITS
EPSDT
Family
Plan
FGHIJK24. A B C D E
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), FORM RRB-1500,
FORM OWCP-1500
APPROVED OMB-0938-0008
Sample
CMS 1500 also known as HCFA: Universal form
used for billing purposes for Health Care
Professionals.
__
__ __ __
1 2
4 TYPE
OF BILL
FROM THROUGH
5 FED.TAX NO.
a
b
c
d
DX
ECI
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
A
B
C
A B C D E F G
H
I J K L
M
N O P Q
a
b
c
a
b
c
d
ADMISSION
CONDITION CODES
DATE
OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE SPAN OCCURRENCE SPAN
CODEDATE CODE CODE CODE DATE
CODE THROUGH
VALUE CODES VALUE CODES VALUE CODES
CODE AMOUNT
CODE AMOUNT
CODEAMOUNT
TOTALS
PRINCIPAL PROCEDURE a. OTHER PROCEDURE b.OTHER PROCEDURE
NPI
CODE DATE CODE DATE CODE DATE
FIRST
c. d. e.OTHER PROCEDURE
NPI
CODE DATE DATE
FIRST
NPI
b
LAST
FIRST
c
NPI
d
LAST
FIRST
UB-04 CMS-1450
7
10 BIRTHDATE 11 SEX
12 13 HR 14 TYPE
15 SRC
DATE
16
DHR
181920
FROM
21 2522 26 2823 27
CODE FROM
DATE
OTHER
PRV ID
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
b
.
INFO
BEN.
CODE
OTHER PROCEDURE
THROUGH
29
ACDT
30
3231 33 34 35 36 37
38 39 40 41
42 REV.CD. 43 DESCRIPTION 45 SERV.DATE 46 SERV.UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49
52REL
51 HEALTH PLAN ID
53ASG.
54 PRIOR PAYMENTS
55 EST.AMOUNT DUE
56 NPI
57
58
INSURED’S
NAME 59
P.REL 60
INSURED’S
UNIQUE
ID
61
GROUP
NAME
62
INSURANCE
GROUP
NO.
64 DOCUMENT CONTROL NUMBER
65 EMPLOYER NAME
66
67
68
69 ADMIT 70 PATIENT
72
73
74
75
76
ATTENDING
80
REMARKS
OTHER PROCEDURE
a
77
OPERATING
78
OTHER
79
OTHER
81CC
CREATION DATE
3a
PAT.
CNTL
#
24
b.MED.
REC. #
44 HCPCS / RATE / HIPPS CODE
PAGE OF
APPROVED OMB NO.
e
a
8 PATIENT NAME
50 PAYER NAME
63 TREATMENT AUTHORIZATION CODES
6
STATEMENT
COVERS
PERIOD
9 PATIENT ADDRESS
17
STAT
STATE
DX
REASON DX
71 PPS
CODE
QUAL
LAST
LAST
National Uniform
Billing Committee
NUBC
™
OCCURRENCE
QUAL
QUAL
QUAL
LIC9213257
CODE DATE
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
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NGL Student Accident Packet (Hastings College)

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Completed 23 July 2020

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