When seeking reimbursement for medical treatment due to injuries from a school activity parents need to collect:

1. Itemized bills with the procedure codes
2. Medical records
3. Receipts and proof of payment for anything paid out-of-pocket if they need to be reimbursed

The Student Accident Program is secondary to any major medical coverage the parents may have. Parents/ students will need to process the claims first through their primary coverage. Then they will need to submit the EOB’s (Explanation of Benefits) from their primary insurance carrier along with the claim form and itemized billing statements with the medical provider’s Tax ID number to the Student Accident claim company. The EOB’s explain what was paid and what is still due.

If parents/ students do not have any other major medical coverage in place then Student Accident Program becomes primary.

Missing paperwork, primary care EOB’s, and procedure codes are the biggest delay for processing claims.

Linked below are the following documents:

1. Claim Fillable Form
2. Instructions to file a claim
3. Sample Medical Provider 1500 Claim Form
4. Sample Hospital Claim Form
5. HIPPA Authorization

ZURICH AUTHORIZATION TO RELEASE FORM

This is an optional form. ACI can attempt to call on behalf of a parent to a medical provider to obtain medical bills with the procedure codes, the Tax ID for the provider, and medical records. However, it is at the medical provider’s discretion if they wish to work with the claim company. ACI needs a HIPAA form signed to provide permission to request that information. I have attached that form.
In the first section, check off the required services that pertain to the student’s treatment.

1. Then check off “Association Representative” and list Administrative Concepts Inc.
2. Also, check off “Specific Individual” if you want an additional person to have permission to work on your behalf.
3. Fill, date, and sign the bottom section completely.

Parents/ students and the school may contact the claim company directly through the phone number or email on the claim form.

If the parents want help from our insurance representative, they can use the secure file transfer link below to upload files:
Upload your files here – Student Accident Claim Submission