MEDICAL GAP AMERICAN PUBLIC LIFE (APL)
secured.ampublic.com 800.256.8606, option 2
The Supplemental Medical Gap plan is designed to help cover your out-of-pocket expenses, such as deductibles, copayments, and coinsurance associated with inpatient and outpatient services of the underlying major medical plan. Be sure to provide your APL ID card along with your J.P. Farley ID card when seeking services from your medical provider so they may file your claim . If your medical provider is unable to accept the assignment of benefits, you may file a claim directly with APL.
If benefits are to be paid to provider, the provider should file the claim to receive benefits. If benefits are to be paid to you, APL will need: z MEDlink claim form (Form C101) from ampublic.com z The Explanation of Benefits (EOB) from J.P. Farley z A uniform itemized hospital bill (Form UB-04) for inpatient and outpatient hospital claims z The physician’s itemized statement of services rendered when filing for treatment in a physician’s office (Form CMS-1500)
Services
Coverage Maximum
Benefits Covered
z Treatment while confined in a hospital
$1,000 per covered person per calendar year $2,000 per calendar year for all covered persons combined
z
z Inpatient treatment of a mental or emotional disorder (max 30 days) z Ambulance service when resulting in hospital confinement z Treatment in emergency room, urgent care, physical therapy facility, surgery, and diagnostic testing z Outpatient treatment of a mental or emotional disorder (max 30 days)
In-Hospital
z
$1,000 per covered person per calendar year $2,000 per calendar year for all covered persons combined
z
Outpatient
z
Ambulance service
z
Emergency Room Deductible
$200 per covered person per occurrence
10
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