Short Term Care and Optional Rider Claim Forms
Please read the important information below: This packet is used for filing your OmniFlex Short-Term Care benefit and optional rider claims. Please be sure your policy number(s) is/are on all documents. The claim form should be completed and signed by the Insured or responsible party. Please attach Power of Attorney or Guardian papers, if applicable. The HIPAA Authorization to Permit Use and Disclosure of Health Information must be signed, dated and included with your submission, in the event we must contact your medical provider for additional information as needed. The Physician’s Health Certification form must be completed by the ordering physician. Include any itemized statements, UB04 or Health Care Financing Administration (HCFA) forms for consideration. We do not pay on any advanced billing . Include any Aide note(s) for your care. Please be sure you answer ALL questions on the claim form. An itemized statement contains: 1. The date(s) of treatment 2. The type(s) of service 3. The diagnosis 4. The medical provider’s name and address. If you are only filing a claim for your Prescription Drug Benefits, please use the separate Prescription Drug
Claim Form provided on the website. Please send all information to:
ManhattanLife Claims Department P.O. Box 925568 Houston, Texas 77292-5568 Or fax to: (713) 583-2738
NOTE: Your Policy may have a Pre-Existing Conditions Limitation and a 2-year Policy Contestability Period. If your claim happened during one of these periods, additional information may be required. If we need to request any additional information and we have your signed HIPAA Authorization, we will handle these requests directly with your medical provider(s) and will notify you of our action and any delays. If you signed a benefits assignment with the provider and you have a balance still due, we are required to pay that balance directly to them; otherwise, benefits will be sent to you. • Processing delays may result if you do not provide all the above information. • For your own records, we suggest you make photocopies of any information or documentation that you send or receive.
For assistance, please contact our Customer Service Department (800) 672-4535
Page 2
STC-CF 0624
Made with FlippingBook flipbook maker