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How to Report an Accident Medical Claim

Accident Claims: This page contains claim forms and instructions to report Accident Medical Claims on NRPA-sponsored Team Sports Adult & Youth Accident and Blanket Accident Policies Only.

To Report Liability Claims for Team Sports and Interns & Instructors Liability Policies, click here.

ACCIDENT MEDICAL CLAIM REPORTING PROCEDURE

ACE American Insurance Company

Download Claim Forms to report Accident Medical Claims Only

YOUR CLAIM FORM

  1. Each policy noted above has a specific claim form that should be fully completed with signatures from both the coach and league official and submitted within 90 days from the date of injury.  Be sure to answer and complete the section regarding “OTHER INSURANCE STATEMENT.” Mark either “Yes” or “No” and complete all sections pertaining to you.  Sign the line for authorization, so that Health Special Risk, Inc. (HSR) and the doctors/hospital may communicate concerning your claim. 

    Incomplete claim forms are one of the most frequent reasons why claim payments are delayed. 
  1. Only one claim form for each accident needs to be submitted.
  2. Once completed, make a photocopy for your records, and mail to the address shown below.
  3. DO NOT assume that anyone else will mail this claim form to HSR for you.

YOUR BILLS

  1. Please advise all doctors/hospitals regarding this coverage so they may forward us their itemized bills.
  2. If you have already been to the doctor/hospital and did not know about this coverage, then please send all of the itemized bills to HSR at the address shown below.
  3. The bills should include the name of the doctor/hospital, their complete mailing address, telephone number, the date you were seen by the doctor/hospital, what the doctor saw you for and the specific itemized charges incurred.
  4. If this information is not on the bill when you send this in we will have to contact the doctor/hospital which will delay the review of your claim.  “Balance Due” statements do not contain sufficient information to complete your claim.

EXCESS INSURANCE

  1. This policy provides coverage on a secondary/excess basis.  If you have any other primary insurance coverage you need to send the bills to your primary insurance first.
  2. HSR will consider benefits after your other, primary insurance has processed the claim.
  3. We will require a copy of your primary insurance Explanation of Benefits (EOB) which you should receive from your primary insurance letting you know what was paid or denied, and the reason(s) why.
  4. HSR will not be able to consider your claim without this information.          

If you have any questions, please contact Customer Service at (866) 345-0975. They are available from 8:00 a.m. thru 5:00 p.m., Monday – Friday. You may also forward any documents by fax to (972) 512-5820.

Health Special Risk, Inc.,4100 Medical Parkway, Carrollton, TX 75007