CogniTel Global Insurance - International Travel, Medical & Health Insurance

IMG Insurance Claims Guide

medical evacuation

The insured is provided with claim information after approval for one of IMG's products. The material the insured receives includes an ID card with important phone numbers, a pamphlet about precertification and an example of a Claim Form. Despite this information, your client may ask you for help at the time of a claim.

The following guide has been designed to give you important claims information. This section will assist you at the time of application or when you have a pending claim and helps smooth the claim process.

The Insurance Claims Guide Is Outlined As Follows:

Precertification

Precertification Review

Continue Stay Review

Medical Evacuations

Important Information

How and Why a Claim is Investigated

Commonly Asked Claims Questions

Examples Of Claim Payments

How Do I File A Claim

IMG Claims Filing Information

IMG Claims Fraud Information

PRECERTIFICATION

Precertification is done by Akeso Care Management, Inc. (ACM), a wholly owned subsiduary of IMG. Visit ACM's website www.akesocare.com for more information about services that ACM offers.

When should you call IMG?

Precertification requirements vary by plan, but generally include:

Physician recommended surgery or treatment requiring hospitalization (including delivery)
Any outpatient surgery or procedure
Within 48 hours after an emergency admission to the hospital
Care in an extended care facility
Home nursing care/home infusion therapy
Durable medical equipment and artificial limbs
Evacuation requests

Who can call IMG to precertify?

The insured, doctor, a hospital administrator or a relative may call IMG to precertify, however, it is the insured's responsibility to assure treatment is precertified.

What information will be needed when calling to precertify?

IMG will ask for the following:

Patient's name
Patient's ID number
Patient's insurance certificate number
Patient's date of birth
Attending Physician's name and phone and fax numbers
Hospital name and phone and fax numbers
Nature of the medical conditions and proposed treatment
Clinical information

What happens after IMG has been contacted for precertification?

After receiving the insured's hospitalization or surgical request and all requested information, IMG reviews the information and recommends certification of hospital stay based on medical necessity. IMG does not determine medical treatment for the insured. The insured and his/her physician make decisions regarding medical treatment.

Note: To expedite and simplify the precertification process for non-urgent care, please visit www.imglobal.com to begin the precertification process. Simply click the "Current Clients" title, then click the "Initiate Precertification" option. You will be asked to complete several information fields which can then be submitted electronically to IMG. The Medical Department at IMG will notify you upon receipt of this email. Once we have received this request, our medical team will review the information you have provided and respond to you within 2 business days. Please note that this online service will only initiate the precertification process, and it should not be used to precertify emergency admissions, procedures or evacuations.

PRECERTIFICATION REVIEW

How is the insured's medical procedure or treatment reviewed?

IMG's Precertification Program reviews the medical necessity and, for inpatient admissions, the anticipated length of stay using national standards and guidelines.
Each case is reviewed separately. Most of the certification requests IMG receives are handled on the first review by the Case manager.

What happens to cases that do not meet national guidelines?

A small percentage of certification requests do not meet national guideline standards. These cases will be referred to IMG'S Medical Director for further review.
Notification of the outcome will be sent via telephone, fax or letter to the insured and physician (or hospital) after the review is complete.

CONTINUED STAY REVIEW

When is continued stay review necessary?

Continued stay review is performed for all insureds who remain in the hospital beyond what IMG had originally certified.
Continued stay reviews are initiated by IMG or the hospital. This will occur on the day the insured is scheduled to be discharged from the hospital. IMG contacts the physician or hospital to determine whether discharge is planned as scheduled, or additional day(s) and continued stay review will be necessary.
The continued stay review continues until the insured has been discharged. Please note, Continues Stay Review follows the same procedures as Precertification Review.

MEDICAL EVACUATIONS

What qualifies as a medical evacuations?

The definition may vary somewhat by plan, but generally must be an immediate threat to life or limb.
The treating physician must concur the medical evacuation is warranted.

What is the process for medical evacuation reviews?

Like Precertification, these are reviewed on a case by case basis, but evacuation requests always take first priority due to their serious nature.
Generally, are to the nearest appropriate medical facility.

IMPORTANT INFORMATION

IMG is available at the following times: 24 Hours a day, 7 days a week for emergencies; 7:00 a.m. to 6:00 p.m. (EST) for non-emergency precertification and general questions.
The website may be used for non-urgent Precertification requests.
Failure to precertify may result in a reduction of benefits and additional penalties.

HOW & WHY A CLAIM IS INVESTIGATED

Why is a claim investigated prior to payment consideration?

To determine if the claim is eligible under the policy.
To determine if the condition is pre-existing.
To determine if the provider of services is eligible.
To determine if the treatment is medically necessary.

How is a claim investigated prior to payment consideration?

IMG will request a Claim Form be completed and submitted for each condition. All questions on the Claim Form must be completed. If not, IMG will return the Claim Form to the insured for completion.
When it is determined that a pre-existing condition investigation is in order, IMG will request medical records from:
- The treating physician
- The hospital(s)
- The referring physicians
- The family physician
- Any other physicians who treated the insured

As medical records are received, they will be reviewed by a Claims Examiner for:

In the event no medical data is available prior to the insured's effective date, the case will be referred to IMG's Medical Director. A decision on the claim will be made using known medical criteria for the insured's condition(s).

COMMONLY ASKED CLAIMS QUESTIONS

Insured persons frequently ask the following questions. If the question you have does not appear here, please contact the Claims Customer Service Department at IMG.

Q: I need to go to the doctor, what should I do?

A: Present your IMG Insurance I.D. Card to the doctor's office when you first visit. The doctor's office should contact IMG to verify benefits.

Q: Are charges covered for a routine physical?

A: Yes, with the following conditions: 1)You purchased a Global Medical Insurance certificate after 1/1/96 and have been covered for 24 months continuously and; 2) You are a female age 35 and over or a male age 35 and over and; 3) Your examinations are separated by 12 months.

Q: I received bills from the hospital, should I pay?

A: Submit your original bills to IMG with a completed Claim Form. Assuming you have met your deductible and the medical expenses are eligible, IMG will pay directly to the hospital.

Q: Some hospitals insist I pay the bill at the time of service. How do I reimburse?

A: Attach your original paid receipts and itemized bill with a completed Claim Form. IMG will reimburse you assuming the deductible and coinsurance have been met and the medical expenses are eligible.

Q: What if I receive a bill for less than my deductible and I have not met my deductible yet?

A: Pay the bill. Then forward the original bill to IMG with a Claims Form. Do not hold the bill(s) until your deductible is met. When the amount of your bills meet or exceed your deductible, IMG will credit the eligible charges toward your deductible.

Q: How long do I have to submit a claim to IMG?

A: It depends on which plan you have purchase:

90 days from the date of services if you have Global Medical Insurance.

3 months from expiration date if you have Patriot Travel Medical Insurance.

Q: Is dental or vision covered?

A: Vision is not covered. Dental will be covered for sound and natural teeth injured as the result of an accident.

Q: Do I have to follow a list of doctors or may I go to any doctor I wish to see?

A: IMG does not use a mandatory list of doctors. You may choose any doctor you wish. However, we are happy to refer you to a healthcare provider should you need one.

Q: How often do I need to complete a Claim Form?

A: Submit one Claim Form for each medical condition or accident you are claiming.

Q: What is a Preferred Provider Organization (PPO)?

A: A Preferred Provider Organization is a group of doctors, facilities and hospitals that have agreed to take a percentage discount for services rendered.

Q: How does the PPO work?

A: The insured selects a provider or facility within the independent Preferred Provider Network. That provider or facility within the network then renders services at a discounted rate.

EXAMPLES OF CLAIM PAYMENTS

An Insured has a US$500 deductible on a Global Medical plan. Insured visits a PPO (in-network) doctor, and is charged US$350. Insured then visits a Non-PPO doctor (out-of-network) and is charged US$600.

PPO/In-Network Charges: Because the deductible is reduced by 50% In-Network, and coinsurance is waived, the charge of US$250 satisfies the deductible and the remaining US$100 is paid at 100%.
Non-PPO/Out-of-Network Charges: Because the insured is Out-of-Network, the full US$500 deductible must be satisfied and coinsurance must be paid. Therefore, US$250 of the US$600 charge, goes toward satisfying the deductible and the remaining US$350 will be paid at 80%.

An Insured has a US$500 deductible on a Global Medical plan. Insured visits a Non-PPO (out-of-network) doctor, and is charged US$350. Insured then visits a PPO doctor (in-network) and is charged US$600.

Non-PPO/Out-of-Network Charges: Because the insured is Out-of-Network, the full US$500 deductible must be satisfied and coinsurance must be paid. Therefore, the entire US$350 is applied to the deductible. The insured still requires an additional US$150 to satisfy the deductible in full.
PPO/In-Network Charges: Because the deductible is reduced by 50% In-Network, and coinsurance is waived, the insured need not finish satisfying the US$500 deductible. US$350 has already been applied to the US$500 deductible which satisfies the US$250 deductible required In-Network. These charges are covered at 100%.

HOW DO I FILE A CLAIM?

In Order To File A Claim You Must Follow These Steps:

All claims must be submitted and receive by IMG within 90 days of the date of service.
Each new illness or accident must have a completed Claims Form submitted. This form must be fully completed. All questions must be answered in detail. All questions must be answered in detail.
All claims submitted must be original itemized billings. Remember to keep copies for your records. IMG will not accept photocopies, balance billings or receipts for payments. All bills must be fully itemized with the patient's name, diagnosis, treatment, date of service, and amount charged.
Your providers may be requested to submit medical records for services rendered. Be sure that all names and addresses are legible.
Submit your completed information and original itemized claims to:

INTERNATIONAL MEDICAL GROUP, INC.
Claims Department
P.O. Box 88500
Indianapolis, Indiana 46208-0500

If you need to talk with us about a claim, call 1-800-628-4664 or(317)655-4500 and ask for your claim's customer service representative, or write to us at the above address or our email address at insurance@imglobal.com.

IMG CLAIMS FILING INFORMATION

Direct Payment to Providers

In many cases IMG works directly with the hospital or clinic, including those outside our independent Preferred Provider Organization, for payment of eligible medical expenses. To file a claim, complete the Claim Form and submit it with original itemized bills. In this case, you will be responsible for your deductible, coinsurance amounts and non-eligible expenses. You can also use IMG Interactive Claim Form (123 kb) Microsoft Word is required to use the interactive form.

Reimbursement

If you have received treatment and need to be reimbursed for out-of-pocket medical expenses, complete the Claim Form and submit your original itemized bills and paid receipts within 90 days. We will reimburse your eligible medical expenses after applying the deductible and coinsurance.

Please remember to submit your bills and receipts as soon as you receive them. Do not hold them until the end of the year. IMG will apply eligible medical expenses to your deductible and coinsurance throughout the year.

IMG CLAIMS FRAUD INFORMATION

In an effort to keep costs low for everyone, IMG actively pursues all claims fraud cases. Below is more information on claims fraud and the procedures we have in place to combat this problem.

110 BILLION US DOLLARS LOST EACH YEAR

According to the United States General Accounting Office, fraud costs an estimated $110 billion annually or as much as 10 cents on every dollar spent on health care.

DEFINITION AND PENALTY

U.S. Code, Title 18, Ch. 63, Sec 1347 contains a federal statutory definition of health fraud as follows:

Whoever knowingly and willfully executes or attempts to execute a scheme

to defraud any health care benefit program;
or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by or under the custody or control of any health care benefit program in connection with the delivery or of payment for health care services, shall be fined under this title or imprisoned not more than 10 years, or both.

DETERRING FRAUD

The best way to combat health care fraud is to have procedures in place to deter and identify fraud before the dollars are paid out. At IMG, we provide fraud education and training to the claims department. We call the patient to verify treatment when the bills look suspicious. We ask that employers educate their employees to review their bills, ask questions and to carefully review the Explanation of Benefits worksheets. If the patient realizes the treatment never took place, they need to notify IMG immediately.

REPORTING IMG FRAUD

Our Fraud Unit is designated for policy holders of IMG Insurance Programs. Please report any fraudulent activity by calling 1-800-628-4664 (001-317-655-4500 outside the United States) or E-mail us here on our Web site. We allow anonymity to the caller or the person reporting the fraud.

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IMG Insurance Claims Guide