Patriot America

Plan Detail

Plan Administrator: International Medical Group | AM Best Rating: A "Excellent" | Underwriter: Sirius International

Claims


CLAIMS NOTIFICATION: All claims and related claim information should be filed with the Company through the Plan Administrator at the contact information below, or online at www.imglobal.com/member as soon as possible:

International Medical Group

Attn: Claims Department

PO Box 9162

 Farmington Hills, MI 48333-9162

USA

Proof of Claim:

When the Insured person receives treatment or the company receives notice of a claim for benefits under this insurance, the Insured Person shall submit an International Medical Group (IMG) Claim Form as a necessary component of the Proof of Claim. An IMG Claim Form may be obtained from the form’s library on www.imgglobal.comor completed online via the MyIMG customer portal.

a) A duly completed, timely submitted and signed IMG Claim Form for each new Illness, diagnosed or Inquiry unless the company waives such requirement in writing.

b) An Authorization for Release of Medical Information when specifically requested by IMG

c) All original Universal Billing Forms, Superbill and statements of service rendered from Physicians, Hospitals, and other healthcare or medical service providers involved with respect to the claim.

d) All original receipts for any costs, prescription medications, fee or expenses that have been incurred or paid by, or on behalf, the Insured Person with respect to the claims, including without limitation all original receipts for any cash and/or credit card payments. The provider of service’s full name, address, telephone number(including area/country code), date of service, description of service, description of service (applicable procedure codes),and diagnosis codes must be included on the receipts.

e) If the claims are submitted electronically, copies of the above items are acceptable; however the company reserves the right to request the original documents.

b) The Insured Person and/or Physician, Hospital and other healthcare and medical service providers and suppliers shall have one hundred eighty (180) days from the date a claim is incurred to submit a complete Proof of Claim. The Company at its option may pend resolution and adjudication of submitted claims and/or may deny coverage due to either of the following:

(i) an incomplete Proof of Claim

 (ii) failure to submit a Proof of Claim

(iii) Insured Person’s, Physician’s or Hospital failure to submit a timely Proof of Claim.

c) The company may require the Insured Person to sign an Authorization for Release of Medical Information to request medical records on their behalf or supply us with additional documentation if we are unable to make a benefit determination based on the submitted Proof of Claim. The Insured Person and/or Physician, Hospital and other healthcare and medical service providers and suppliers shall have sixty (60) days from the date of the request to submit the requested information. If the information is not received within the designated time period, previously submitted and subsequent claims will be denied.