Claim Filing Instructions
PLEASE READ THIS INFORMATION CAREFULLY. IT IS VERY IMPORTANT.
ALL INFORMATION MUST BE PROVIDED IN ORDER FOR YOUR CLAIM TO BE PROCESSED TIMELY. INCOMPLETE INFORMATION WILL CAUSE DELAYS IN PROCESSING. NOTE: The accident policy benefits are limited and may not provide 100% coverage. Accident medical expense coverage under the policy is provided on an Excess Basis, and in most instances, benefits will only be paid under the policy after your own personal or group insurance has paid out its benefits. Completion of a claim form does not guarantee benefit payment. Each claim is reviewed according to the policy provisions.
Obtain a claim form on this site using the instructions above or from your marketing agent, organization or school and answer all questions in detail (including all signatures on the front and back of the form).
Example of How to Complete a Claim Form.
A claim form needs to be completed for each accident. Print or type clearly on the claim form and refrain from using abbreviations for your city or county. Be specific in your description of what happened.
- Give the health care provider your primary insurance information, if any, and the following information so they can send the proper claims documents to the claims administrator (WebTPA):
If you have other insurance, file your claim with your primary insurance company. They will send you an Explanation of Benefits (EOB).
Here is a sample EOB. After you receive the EOB you can file the claim with us either by email or fax using the contact information above or electronically by clicking here. The fully completed claim form, EOB and itemized bills should be
submitted within 90 days of the date of medical care treatment. Balance due notices submitted in lieu of itemized bills will not be processed. Itemized bills include:
HCFA-1500 (standard form used by Providers)
Here is a sample HCFA-1500.
UB-04 or UB-92 (standard form used by Hospitals)
Here is a sample UB-04.
ADA Dental Claim Form and letter from the dentist verifying the injured tooth was whole, sound, and natural are required.
Here is a sample ADA claim form. All dental bills must be submitted through your primary insurance’s medical and dental plans first before submitting the bills to WebTPA.
- If you have already paid the provider’s bill, include a paid receipt, or copy of your canceled check when submitting the bill for reimbursement. Unless proof of payment is received at the time the bill is submitted, payment will be made to the provider of service (Hospital, Physician or Others).
- If you change your address, please notify WebTPA by calling the number on the claim form so there is no delay in processing any claims.
- To check the status of your claim, or if you have questions on how your claim was processed or the benefit paid, call the number on the claim form. Please allow 15 days before calling to check the status of your claim.
KEEP COPIES OF ALL CLAIM FORMS, BILLS, AND CORRESPONDENCE FOR YOUR OWN RECORDS UNTIL YOUR CLAIM HAS BEEN PROCESSED.
FILE MY CLAIM ELECTRONICALLY