Claim Procedures

Hospitalization or Surgery Benefits.
A claim form should be completed for each claim involving inpatient Hospitalization or Surgery expenses. The completed claim form and itemized bill(s) should be mailed or faxed to the Claims Administrator.

All Other Benefits.
A claim form is not required for submission of expenses for benefits other than inpatient Hospitalization or Surgery. Simply mail or fax itemized bill(s) to the Claims Administrator.

For All Benefits.
An itemized bill must include the following information:

- employee's name and Social Security Number;
- employer's name and Sponsor Number;
- patient's name;
- diagnosis code(s);
- procedure code(s);
- provider's name, address, phone number, tax ID number;
- provider's signature.

Claims should be submitted within 30 days of the event.
All claims should be submitted to: