Student Athlete Insurance Network S.A.I.N Student Athlete Insurance Network

How to File a Student/Athlete Injury Claim: Go to https:/www.studentinsuranceusa.com/school-list/ Locate your DISTRICT Click on Claim & HIPPA Form link Download or open with a different viewer to access the fillable function for the Anthem Blue Cross Claim Form & HIPAA forms You can save the blank form to your desktop for easy access. Complete the claim forms from your desktop computer then print and sign as the College Official The student MUST sign twice on the claim form and once on the HIPAA form Please review the 2 example forms below the “download” link to ensure all mandatory fields are completed.

Mandatory Fields on Claim Form: MUST have Date of Injury Include name of parents IF the student has other insurance through parent – or if student prefers parents to communicate with Student Insurance If no other insurance indicate: “No other Insurance” Student must sign here Group # will ALWAYS be the same: 1157 QS Student must sign here College Official must sign Here If student is a minor guardian/parent must complete Student must sign here

Submitting Claim Forms: Submit the completed claim & HIPAA forms to our office by any of the following methods: E-Mail (recommended): claims@studentinsuranceusa.com Fax: 310-826-1601 Mail: Student Insurance 10801 National Blvd. #603 Los Angeles, CA 90064 Please submit the claim forms to our office as soon as possible to expedite the insurance benefits process. The student must take a copy of the claim forms and present it to each health-provider they seek treatment with, as the claim forms serve as proof of insurance. Keep a copy for your records !

Anthem Claim Control Number: ‘N’# An Anthem Blue Cross claim control number better known as: ‘N’ number will be assigned once Student Insurance receives the completed injury claim forms. The ‘N’ number is a specific set of numbers given for each injured student. The ‘N’ number is needed for billing purposes and claim status. If a student needs to schedule an appointment with a health-provider immediately, please let us know by requesting the ‘N’ number at the time of submitting the claim form. Anthem will assign an ‘N’ number for a student within 1-5 days. If more than one claim is filed by a student the ‘N’ number will remain the same for all claims. N# = The letter N followed by 8 digits: N01234567

Insurance Benefit Maximum Athletic Injury Maximum (per injury): $25,000.00 Student Injury Maximum (per injury): $50,000.00 Dental Injury Maximum (per injury): $2,000.00 Athletes that are injured during the off-season or a conditioning class are considered ‘Student injuries’. Emergency Illness Benefit Maximum: $500.00 Emergency Illness Benefit: Any medical condition that is linked to illness and not a physical injury. (example: fainting, dizziness, nausea, vomiting, dehydration etc.) The Emergency Illness Benefit cannot be granted unless written authorization from a College Administrator is received, stating that the College authorizes this benefit

Anthem Blue Cross PPO – S.A.I.N. The Student Athlete Insurance Network (S.A.I.N.) injury insurance policy is through Anthem Blue Cross and is an unrestricted (no referral needed) PPO plan. The insurance is accidental injury insurance only and cannot be used for illness or sickness The policy is valid for one (1) year from the date of injury. Once the 1 year is up the student’s benefits will be termed/exhausted. The policy does not have any extensions after the 1 year mark – no exceptions. In order to be eligible for benefits - the student/athlete MUST be treated for the injury within 120 days from the date of injury. If the student’s 1st treatment is after 120 days the claim will be denied by Anthem Blue Cross. To be covered at 100% the student must seek treatment with an Anthem Blue Cross PPO provider.

In-Network Providers: Always advise students to seek treatment with an Anthem Blue Cross PPO provider to be covered at 100%. To Find an In-Network Provider: 1. Go to www.studentinsuranceusa.com 2. Under the ‘Other Services’ tab from the toolbar – click “Anthem Insurance Network Providers” 3. Refine the search to meet the student’s needs. 4. Click search and a list of Anthem providers will generate within the specified zip code.

Contact Information If you, or a student/athlete, have any questions please call our office at any time at 310-826-5688 or email us at claims@studentinsuranceusa.com Student Insurance 10801 National Blvd #603 Los Angeles, CA 90064 Phone: 310-826-5688 | Fax: 310-826-1601 claims@studentinsuranceusa.com