claim forms
Before you see a doctor, you will have to sign some forms. One of the very first will be a blue form either on or near the top, telling you that you are the guarantor. This means that you are responsible for payment for services received.
Your insurance policy is an agreement between you and your insurance company. NOT you, your insurance company and whatever medical service provider you see. The Insurance company and the doctors office may work together as a convenience to you, but only as a convenience, not because they have to. Until the bill is actually paid, you are the responsible party. For these reasons, it is very important that you
always file a claim form!
To file the claim form means to fill out the needed forms, sign them and fax or mail them to the insurance companies Claims Office. The claim form will have the claims office address on it. Make sure you send your forms to the proper address. Keep copies of everything you send.
The Forms:
- The medical claim form is the main form; Always file this one.
Click here for the Medical claim form
- If your claim was caused by a accident as opposed to an illness, file the accident form. If in doubt, file the accident form anyway.
Click here for the Accident Questionnaire
- If you need or want someone to help you with the process, you must name them on the Privacy & Confidentiality (P&C) form and file that. Without the privacy form the insurance company cannot discuss your claim with anybody but you.
Click here for a P&C Release form
- Click here for a Dental claim form
- Click here for a Baggage Claim
precertification
Each proposed hospital admission, inpatient or outpatient surgery, and other procedure as noted in the Certificate Wording must be Precertified for the medical necessity, which means the insured person or their attending physician must call the number listed on the IMG identification Card prior to admittance to a hospital or performance of a surgery. In case of an Emergency Admission, the Precertification call must be made within 48 hours of the admission, or as soon as reasonably possible. If a hospital admission or a surgery is not Precertified, eligible claims and expenses will be reduced by 50%. Precertification is no an assurance of coverage, a verification of benefits or a guarantee of payment. All medical expenses must meet usual reasonable, customary and eligible payment guidelines. Please referr to the certificate Wording for full details of the percertification requirements.
For precertification, emergency evacuation and repatriation, please call:
IMG in the US: 1–800–628–4664 (toll free) or 1–317–655–4500.
Call IMG outside the US: 001–317–655–4500 (collect if necessary).
This information will also be provided on your ID card.
Begin the Precertification process only (not to be used for Emergency Evacuation or repatriation).