Accident Questionnaire Form (Page 2 of 2) in pdf

Frequently Asked Questions

Why do we need this information?

Your health contract contains an important clause called “subrogation” or “reimbursement.” This means when

BlueCross BlueShield of South Carolina pays medical bills for an injury or illness that has been caused by a third

party, we have a right to seek reimbursement of those medical bills from the third party, their insurance company,

and/or your insurance company. We also have the right to seek reimbursement of the medical bills from you if you

receive a settlement from the third party or an insurance company for this injury or illness.

How did we identify your claim as a potential subrogation or workers’ compensation case?

Our staff of physicians has established a list of diagnosis codes that indicate an injury or illness may be accident

related or work related. When claims are processed through our system, a questionnaire is generated if the patient

has received treatment for an injury or illness that has one of these “accident-type” diagnosis codes.

How does subrogation help you?

These subrogation/reimbursement procedures help to contain the cost of healthcare by reducing premium costs paid

by you and/or your employer and also reducing the amount of benefits applied to your lifetime maximum benefit

amount.

What if you were injured on the job?

Your health contract also contains a provision that excludes the payment of medical bills for work-related injuries

and illnesses. This means that we will not provide benefits if workers’ compensation laws cover, provide or pay for

the service, supply or treatment of any work-related accident or illness. In addition, if you receive a settlement for

your workers’ compensation claim, we consider the settlement payment to be covered by workers’ compensation and

we will not provide medical benefits for the injury or illness.

Does this questionnaire only apply to work-related accidents?

No. If another person caused your injury or illness or may be responsible for your injury or illness, you need to

complete this form. We cannot provide you with an entire list, but here are just a few of the types of accidents we

need to know about: car accidents, motorcycle accidents, work-related injuries, injuries on another person’s property

(such as falling in the grocery store), medical malpractice, defective products or machinery, food poisoning, etc.

What if this claim was not accident related or if no one else was responsible for the injury or illness?

The only way we will know if your claims are or are not accident related is if you complete and return this form.

After we receive your information indicating this was an illness for which no one else is responsible, we will make

sure your claims are opened for processing and we will notate your information in our system to avoid having future

questionnaires sent to you for the same accident.

What do you need to do?

It is very important that you complete this easy questionnaire and send it back to us. Your answers will help us

properly administer your claims and determine if we need to seek reimbursement from a third party or an insurance

company for these claims. If you do not return the questionnaire, we may withhold payment on your medical claims.

The subrogation/reimbursement and workers’ compensation clauses in your health contract require you to notify us if

you receive an award or settlement from a third party or an insurance company. From that award or settlement, you

must reimburse BlueCross BlueShield of South Carolina for any medical benefits that we have paid for this injury or

illness

What if you still have questions or need help completing this form?

Please contact us at 1-800-288-2227, extension 43060, for more assistance.

Accident Questionnaire Form Page 2