US Club Medical - Dental Accident Youth Claim FormUpdatedThursday July 28, 2022 byLeague Registrar.
Send completed Youth Claim Form to:
US Club Soccer-registered members may use this form to file an accident medical/dental insurance claim for an injury that occurred during a US Club Soccer-sanctioned activity.
Policyholder: National Association of Competitive Soccer Clubs, doing business as US Club Soccer
Excess coverage: Accident medical expenses are covered under this policy on an excess basis, and benefits will only be paid under this plan after your own personal / group insurance (including Health Maintenance Organizations) has paid out its benefits. Please note that you must follow your primary insurance carrier's eligibility criteria (i.e., to be treated in-network, if required by HMO, etc.) for this policy to consider your expenses for payment. Payment under this policy will be made according to usual and customary guidelines. This means that the basis for payment of specific medical or dental services is based on the average cost of that service by region. This policy does not automatically pay for services in full; it pays based on the “usual and customary” fee for that service in your area. Once the $500 deductible has been satisfied, benefits are payable at 80% of the allowable rate. Additionally, some benefits may be subject to internal policy limits.
Claim eligibility timing: For claims to be eligible for coverage, this form must be submitted no later than 90 days after the date of injury, and medical attention must be received no later than 60 days after the date of injury.
Benefit period: This policy is subject to a 52-week benefit period from date of injury. Medical or dental expenses that are incurred within 52 weeks of the date of injury are eligible for coverage under this policy. Any expenses or treatments that are rendered after the 52-week benefit period will not be covered by this policy.
1. Submit this form to US Club Soccer. The claimant, or a parent/guardian if the injured person is a minor, is to complete this form in its entirety (with the exception of the Club/Member Organization Verification and US Club Soccer Authorization sections) and email it to US Club Soccer at firstname.lastname@example.org. Please do not send bills, Explanation of Benefits (EOBs), or other information to US Club Soccer.
2. Internal US Club Soccer verification. After you submit this form, US Club Soccer will review claim eligibility and verify the accident with the claimant’s club/member organization.
3. Post‐verification claim status update. You will receive an email with the claim status when the verification is complete. If approved, US Club Soccer will then submit the claim to A-G Administrators, the claims processor.
4. Communication and instructions from A‐G Administrators. You will then receive communication from A-G Administrators with instructions for you/your providers to submit documentation (bills, EOBs, etc.) directly to:
PO Box 21013
Eagan, MN 55121
Phone: (610) 933-0800
Fax: (610) 933-4122
Itemized bills are required:
HCFA‐1500: Standard form used by providers, such as doctors and dentists, to show the medical treatments and charges made for each service.
UB‐04 or UB‐92: Standard form used by hospitals to show medical treatments / charges made for services.
Explanation of Benefits (EOB) from your primary insurer(s), if applicable.
Payments will be made to you, if the itemized bills indicate that they have been paid. Otherwise, payments will be made directly to the doctor, hospital or other service provider. All dental bills must be submitted through your primary insurance’s medical and dental plans first before making a claim for dental treatment under this policy.
|US-Club-Soccer-Accident-Medical-Dental-Insurance-Claim-Form-Youth - Updated May 2022|