US Club Medical - Dental Accident Youth Claim Form

UpdatedThursday May 6, 2021 byLeague Registrar.

Send completed Youth Claim Form to:

insurancequestions@usclubsoccer.org

Or by mail to:

US Club Soccer - Claims Dept

716 8th Avenue North

Myrtle Beach, SC 29577

 

A Medical Claim form and an Insurance Claim Verification form must be submitted to US Club Soccer before the claim is forwarded to A-G Administrators, Sports Insurance Specialists for processing.

IMPORTANT: ALL INFORMATION MUST BE PROVIDED IN ORDER FOR CLAIM TO BE PROCESSED

1. 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 innetwork, if required by HMO, etc.) in order 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.

2. Claim Guidelines: You have 90 days from date of injury to submit claim form. For claims to be eligible for coverage, you must seek medical attention within 60 days from 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.

3. Please remember:

a) Once the Youth Claim Form has been authorized by US Club Soccer, you can advise your doctors / hospitals of this program. Once your primary insurance has processed the bill, the medical provider can then file claims directly with A-G Administrators , P.O. Box 979 Valley Forge, PA 19482. Phone 610-933-0800. Do not send bills, EOB’s or statements to US Club Soccer.

b) Itemized bills are required: You or your providers must submit itemized bills; balance due bills or notices. Forms needed are noted below. 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.

• 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.

• Primary Insurance Explanation of Benefits (if applicable).

4. Dental bills: 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 Medical - Dental Accident Youth Claim Form.pdf