img interactive claim form - international medical group

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1、ClaimFilingInstructions&ClaimFormPleasefollowtheseinstructionspriortofilingaclaimandwhencompletingtheClaimForm.AssistanceisalsoavailablefromtheInternationalMedicalGroup®(IMG®)CustomerServiceDepartmentatthetelephonenumberslistedbelow.IFYOUHAVENOTYETRECEIVEDTREATMENT:Pre-ce

2、rtification(notificationofillnessoraccident):YoumustcallIMGtopre-certifyanyofthefollowingconditions:anytreatmentrequiringhospitalization;outpatientsurgery,CATscans,MRI’s;within48hoursafteranemergencyadmissiontothehospital;careinanextendedcarefacility;homenursingcare;durab

3、lemedicalequipmentincludingartificiallimbs;ortransplants.Pre-certificationmaybedonebyyou,arelative,orahospitalrepresentative.IndependentPreferredProviderOrganization(PPO):YourplanmayrecommendyoureceivetreatmentfromaproviderwithintheUSPPO.Youmayaccessalistingofphysiciansor

4、facilitiesby:·UsingtheIMGwebsite,www.imglobal.com.Thisprovidesacompletelistingofprovidersbyspecialtyandgeographiclocation.·ContacttheIMGCustomerServiceDepartmentatthetelephonenumberormailingaddresslistedbelowforalistofprovidersinyourarea.Pleasenote,duetothesizeofthePPOnet

5、workwecanonlysenddirectoriesforyourimmediatearea.WhenreceivingtreatmentfromaPPOprovider,pleasefollowtheseinstructions:·PresentyourIMGmedicalidentificationcardtotheprovider.·RequestthattheprovidersendthebilldirectlytoIMG.Pleasenote,ifyoupaydirectlytotheproviderforaneligibl

6、eexpensethiswilllikelyaffectyourreimbursementfromIMG.Thenegotiatedfeeforserviceswillbethemaximumreimbursement,whetherpaidtotheproviderortoyou.·CompletetheClaimFormandsubmititwithalloriginalbillsorinvoices.Iftheproviderhasfiledtheclaimsonyourbehalf,simplyforwardthecomplete

7、dClaimFormtoIMG.·WhenreceivingtreatmentfromaPPOproviderforeligibleexpenses,thesubmittedbillsmustbere-pricedthroughthePPOtothenegotiatedrate.Thisproceduremayextendthenormalprocessingtimeofyourclaim.IFYOUHAVEALREADYRECEIVEDTREATMENT:·Ifthisisanewclaim,completeALLPARTSoftheC

8、laimForm.IftreatmentwasreceivedintheUnitedStatesyoudonotneedtocompletePARTC.·Ifthisisacontinuing