Claim Filing Procedures - Accident & Sickness Claims Only
Please submit clear copies or originals of all required paperwork.
Although the claims process is simple, it requires YOUR PARTICIPATION. Please follow the instructions below so that we may process your claim on a timely basis.
Your ID card is included with this notice – please carry it with your major medical ID card. When visiting a provider, present both cards. Providers can then verify both your major medical and supplement coverages, and know where to submit claims for processing. Although every provider has their own procedures for deductible expenses, presenting the card should alert them to the fact that you have a supplemental plan designed to alleviate you having to pay this expense up front. Encourage your provider to contact our customer service department if they have questions as to how the plan works and we will be happy to assist.
For covered Physician visits, In Patient Hospital Confinements, and Out Patient Services, SIS will need the following in order to process your claim:
- A completed claim form. A form is not required for every physician visit, however, we will need at least one in your file annually. Remember to include a completed claim form with your first submission for each year. Be sure to complete the Statement of Insured on the claim form, sign and date the authorization section, and sign and date the claim form for your dependent children (if covered and submitting a claim on their behalf). You may obtain a claim form here, by visiting the Special Insurance Services website at the following link: http://www.specialinc.com/forms/benefitconnection/claim-form.pdf, by emailing a request to firstname.lastname@example.org, or by calling or faxing a request to the SIS Customer Service numbers shown below.
- A copy of the original itemized bill. If your provider has not submitted this directly to us, it is up to you to obtain a copy and submit it for claims processing. The itemized bill must show the diagnosis for your visit, date of service, itemized charges, and the name/address/tax ID of the provider. A balance due statement is not sufficient.
- A copy of the explanation of benefits from your major medical carrier that corresponds to each itemized bill. This is the statement from the primary carrier that tells what charges they are paying, denying, or applying to deductibles, etc. If you participate in an HMO, you will most likely not receive an explanation of benefits. In this case, please be sure the itemized bill you submit includes any HMO payment amount, discounts, write offs, or copays that were paid to the provider.
You may fax, mail or email these items to:
ATTN: Claims Department
Special Insurance Services, Inc.
PO Box 250349
Plano, TX 75025-0349
Fax: (972) 960-0377 or (214) 291-1301
SIS Customer Service: (800) 767-6811 or (972) 788-0699
IMPORTANT!! The Out Patient II benefit is a "per family per calendar year” benefit. The calendar year maximum payable for any one individual within the family unit, however, will not exceed 50% of the family calendar year maximum. The calendar year maximum payable for any covered person who has selected Employee Only coverage, will not exceed 50% of the family calendar year maximum shown in the Policy/Certificate.
ITEMS NOT COVERED: Certain items may not be covered under this plan, including, but not limited to: wellness or preventive care expenses (physicals, pap smears, mammograms, prostate exams, etc.), well newborn care (in or out of the hospital), prescription drugs, durable medical equipment, vision expenses, dental expenses, and claims filed more than one year after the expense was incurred. Please refer to your individual certificate for details.
A Certificate of Insurance has been delivered to your employer in electronic format. To obtain a complete copy of the Certificate of Insurance, please contact your Human Resource Department.