Proof Of Claim Form Page 2
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1
2TO: Parent or Guardian
STEPS TO FOLLOW WHEN FILING A CLAIM:
1.
Only one claim form for each accident needs to be submitted.
2.
The claim form and benefit summary are available at our website: However, this is not a guarantee of benefits but
only an explanation that is subject to all applicable terms, conditions, limitations and exclusions of the plan.
3.
A school official must complete Part A for all school related accidents. The parent or guardian must complete all questions in Part B – Parent
Statement. If the accident is not school related, parent or guardian may complete Part A. Print a copy of the claim form to present to the
treating physician or facility so they might understand what is needed from them to process your claim. Do NOT depend on the medical
provider to submit the claim form. You should submit the claim directly to claims office within 90 days from date of injury.
4.
You will need to send copies of itemized bills. These are the original billings you receive, not monthly statements. These itemized bills
often called UB04 or CMS 1500 provide the Address, Procedure Code, Diagnosis Code, and the Provider's Tax ID Number.
5.
You will need to submit copies of all bills to your family and/or group insurance, even if you have a large deductible. This plan is supplemental
to all other valid coverage. You must file a claim with your other insurance first. This plan does not cover penalties imposed for failure to
use providers preferred or designated by your primary coverage. After you have received payment or copies of “Explanation of Benefits” (EOB)
from your family insurance company or insurance administrator (Blue Cross, Group Health, Prudential Insurance, etc.), send copies of
itemized bills and your other insurance E.O.B.'s to: (Does not apply to our primary plans)
STUDENT ASSURANCE SERVICES, INC.
P.O. BOX 196
STILLWATER, MN
55082-0196
NO CLAIM CAN BE PROCESSED UNTIL ALL OF THE FOLLOWING DOCUMENTS HAVE BEEN PROVIDED BY
YOU OR THE MEDICAL PROVIDER.
1.
Completed Claim Form
2.
Itemized Bills (UB04) (CMS 1500)
3.
Explanation of Benefits from primary insurance (EOB)
TO FILE A CLAIM FORM ON-LINE
Please complete the form fully and follow all steps explained above. When you are satisfied that the claim form is ready to be submitted
to SAS, make a copy of the completed claim form to present to the physician or facility as explained above, then either:
a. Mail the claim form with any necessary supporting information, to Student Assurance Services, Inc., P.O. Box 196, Stillwater, MN
55082. Please keep a copy of the claim form your records; OR
b. Click on “Submit Form” in the upper right hand corner of the claim form to electronically send the claim form to SAS. If you have any
additional or supporting information mail it to Student Assurance Services, Inc., P.O. Box 196, Stillwater, MN 55082.
PLEASE REFER TO THE MASTER POLICY ISSUED TO THE SCHOOL/SCHOOL DISTRICT FOR SPECIFIC DETAILS.
ATTENDING DENTIST'S STATEMENT
(1) DATE OF ACCIDENT
(3) WERE THE TEETH SOUND OR NATURAL PRIOR TO THE CURRENT
TREATMENT?
YES
NO
(2) IF PROTHESIS, IS THIS INITIAL PLACEMENT?
(4) ARE ANY SERVICES COVERED BY ANOTHER PLAN?
YES
NO
IF SO, NAME PLAN
YES
NO
IDENTIFY ALL TEETH WITH AN “X” THAT
WERE INVOLVED IN THIS ACCIDENT
TOOTH
DATE OF
DESCRIPTION OF SERVICE
FEE
NO.
SERVICE
TOTAL FEE
x
PROVIDER'S NAME
SIGNATURE
DEGREE
STREET ADDRESS
DATE
(
)
CITY
STATE
ZIP
TELEPHONE
Federal ID Number — No benefits can be paid until we have your ID number.
Page 2
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