Claim Form - Compass Benefits Group Page 2
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2CLAIMS PROCESS
1. After you receive treatment at a PPO provider, the provider will usually submit the charges directly to the claims administrator for
you. In this case, you will receive an Explanation of Benefits indicating what the insurance covered. The provider will then bill you for
any remaining charges, such as your coinsurance amount. You do not need to send balance billing statement (after the insurance has
paid) for reimbursement, as that is your responsibility to pay.
2. If you are asked to pay up front for medical treatment you receive, or if the provider does not send the claim to the claims administrator,
you will need to submit a claim for the portion of the charges for which the company is responsible. Submit itemized hospital and
medical bills with a completed claim form to:
Personal Insurance Administrators, Inc.
P.O. Box 6040
Agoura Hills, CA 91376-6040
3. If you fill a prescription, you must pay in full at the time of pick up. You will then need to submit a claim for reimbursement for the
portion of the charges for which the company is responsible. Submit the itemized prescription drug receipt with a completed claim
form to:
Personal Insurance Administrators, Inc.
P.O. Box 6040
Agoura Hills, CA 91376-6040
4. If you prefer to send your claim form and bills electronically, please scan each document and email to: .
5. If you have questions about the status of your claim after it has been submitted or for any questions about benefits, please call Personal
Insurance Administrators, Inc., at 1-800-314-3938, Monday–Friday, 6:30 a.m. to 5:00 p.m. (4:00 p.m. on Fridays) PT. Always keep a
copy of all documents submitted for claims.
ITEMIZED BILL REQUIREMENTS
Hospital and Medical Bills
A fully itemized billing statement is required for claims payment consideration. The itemized billing statement must include the following:
•
Patient’s name
•
Patient’s date of birth
•
Provider’s name
•
Provider’s address
•
Provider’s tax identification number
•
Diagnosis code(s)
•
Date of service
•
Procedure code(s)
•
Amount charged for each procedure
Note: If your billing statement does not include this information, please contact the provider and ask them to send a copy to you to
include with this form. (The fully itemized billing form is also known as a HCFA 1500, CMS 1500, UB04, and CMS 1450.)
Prescription Drug Receipts
A fully itemized prescription drug receipt is required for claims payment consideration. The prescription drug receipt must include:
•
Pharmacy name
•
Patient’s name
•
Name of the medication(s)
•
Prescribing physician’s name
•
Dosage
•
Date of service
•
Amount charged
Note: Please do not send a cash register receipt listing only the charges. You must send the full receipt or print-out that includes all of
the above.
If you (or the medical provider) don’t provide the itemized bill as indicated above, your claim may be denied until the information is
provided.
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