|
How To File a Claim
You may download a USAble Administrators claim form in PDF (portable document
format). This file will allow you to print a copy for completing off-line.
Once the form is completed, please sign and date it. Mail it to the following
address:
USAble Administrators
P.O. Box 1460
Little Rock, AR 72203
A separate claim form must be submitted for each patient when sending bills to
USAble Administrators.
If you have a problem downloading the form, please call Customer Service at the
number on your ID card or e-mail
Customer Service
.
The following is a breakdown of the claim form:
| 1. |
Group Number and Name |
| 2. |
Employee's Social Security Number |
|
Sections 3-13 request information about the patient:
|
| 3. |
Patient's Last Name, Complete First Name, Middle Initial |
| 4. |
Date of Birth (Month, Day, Year) |
| 5. |
Sex |
| 6. |
Patient's Relationship to Employee (Self, Spouse, Child, Other--specify) |
| 7. |
Diagnosis or Nature of Illness or Injury |
| 8. |
Was this an accident? |
| 9. |
If yes, date of accident |
| 10. |
Was this an automobile accident? |
| 11. |
Was the illness/accident related to employment? |
| 12. |
Is patient a full-time student? |
| 13. |
If yes, what school? |
|
Sections 14-16 request information about the employee (contract holder):
|
| 14. |
Employee's Last Name, First Name, Middle Initial |
| 15. |
Assignment: Payment for this claim should be made to (Hospital, Doctor,
Employee) |
| 16. |
Employee Address |
|
Sections 17-22 request other insurance information:
|
| 17. |
Do you have other health insurance with a group or government program? |
| 18. |
Name of Insured |
| 19. |
Name and Address of Insured's Employer |
| 20. |
Name and Address of Other Insurance Company |
| 21. |
Policy Number (other company) |
| 22. |
Type of coverage (Single or Family); Has the other insurance company paid on
this claim? If yes, please submit a copy of their payment with these bills. |
|