• Complete of the claim form in full each time you are seen for a new Sickness or Injury. Answer all questions, even if the answer is "none" or "N/A."
  
  
• Bills submitted must include the original detailed Physician's bill, including:
  
  
• • Patient's Name
• • Insured's name
• • Name of sponsor through which you are offered insurance (i.e. school or institution)
• • Charges incurred
• • Diagnosis
• • Date of service
• • Federal Tax ID Number of the provider -- you may need to ask the provider for this.
    
    
• If there are no physician's charges, such as when services are rendered at a Student Health Service (SHS), you will need to ask the physician or provider to complete Part B of the claim form indicating the date seen and the diagnosis. Please include the full name and address of the provider. Part B of the claim form is found on the reverse side of the form.
  
  
• If another health insurance plan is the primary payer, you must include a copy of the other plan's Explanation of Benefits (EOB) when you submit your claim form.
  
  
• Be certain that the name on the bill you are submitting is the same as that which is indicated on your ID card. If not, please enclose a short note of explanation.
  
  
• Automobile Coverage - Benefits payable under this Plan will be coordinated with any other automobile coverage. Benefits under our Plan will also be coordinated with benefits provided or required by any no-fault automobile coverage statute, whether or not a no-fault policy is in effect. This Plan will be applied on a secondary basis to any state mandated automobile coverage for services and supplies eligible for consideration under this Plan.
  
  
• All claims must be filed with our office within the twelve (12) month period from the date of the incurred expense.
  
  

Following these instructions will expedite the payment of your claim.