Summary of Benefits
1
This chart serves as a summary only. For a full description of the coverages provided please refer to the master
policy kept on file with Hart Travel Partners
Lifetime Medical Maximum
$500,000
Deductible
$0
Co insurance Rate
The Company Pays 100% of the UCC
Prescription Drugs
$1,000
Surgical Treatment
Covered to the maximum benefit
Mental & Nervous Disorders
Treated as any other medical condition
Pregnancy
Covered as any other medical condition;
conception must occur while policy is in force
Sports Related Injury
$3,000
Accidental Death & Dismemberment
Emergency Medical Evacuation
$500,000
Repatriation of Mortal Remains
$500,000
Comprehensive Security Evacuation
$250,000
Pre existing Condition Limitation
3 Month for prescription drugs only
Trip Interruption
$2,000
How to File a Claim
Print and fill out the below claim form. Be sure to complete every question and attach
itemized bills
Send via email to
aciclaims@visit aci.com
, or via fax 1.610.293.9299
You may also mail your claim documents to
Administrative Concepts 994 Old Eagle
School Road Suite 1005 Wayne, PA 19087
Be sure to send in your claim within
90 days
of the treatment as this is the designated
incurral period
As you are traveling overseas, there may be cases where you will need to pay for the
medical services up front and submit your claim form for reimbursement. Be sure to keep
all of your receipts and any other documents provided to you by the facility.
In non emergency situations, you should call Assist America first for referrals to English
speaking facilities in your area. In emergency situations, you or someone who can
represent you should call the assistance carrier as soon as possible. Contact information
will be listed on your ID Card. We also recommend saving the number in your cell phone
(if applicable) under emergency contact, medical services.
Assist America provides a
free
application for insured’s. If applicable you should download
the application prior to departure. For more information, and to download the app,
please visit
http://itunes.apple.com/us/app/assist america mobile/id463805175?mt=8
In order to check the status of your claim, you may call Administrative Concepts at 1 888
293 9229, or email
aciclaims@visit aci.com
. For assistance with claims you can also email
[email protected]
or contact 1 212 693 3717.
Online claim status is available through
https://secure.visit aci.com/insuredlogin.asp
. It is
recommended that you create an account prior to departure. The information needed to
enroll will be provided to you on your ID card.
Group Plan or Program:
Name of Insured Individual:
Present Address:
Home Address:
Telephone Number:
Date of Birth:
Male Female (Circle One)
If payment is to be made to someone other than the
Insured, who is to receive payment?
Relationship to insured:
Address:
Date of Accident or Sickness:
Nature of Accident or Sickness:
If accident, describe fully how
and where accident occurred:
If injured in play or practice of sport, indicate what sport:
Is the insured covered under any other group plan, health maintenance organization, government plan, or insurance policy?
Yes ❏
No ❏
Insurance Company:
Policy Number:
Are you covered as a dependent under this policy? Yes ❏
No ❏
INSURED OR PARENT MUST SIGN BELOW:
IF PAYMENT IS TO BE ASSIGNED TO PROVIDER, SIGN
Authorization: I hereby authorize release to
BELOW:
Administrative Concepts, Inc., any and all
Authorization: I hereby authorize payment of medical
information concerning advice, care or treatment
benefits to the medical provider identified on this form, for
provided to myself or any of my family which may
the service described.
be needed to process this claim.
Administrative Concepts, Inc. does not share private health information except as required or permitted by law.
We are committed to guarding the private information entrusted to us.
Insured’s Signature:
Insured’s Signature:
Date:
Date:
Physician or Provider Information (Please Attach Universal 1500 Form or Fill Out In Full Below)
Date of First Symptom of Illness
Date First Consulted you for
Has Patient Ever Had Same or
or Injury:
this condition:
Similar Symptoms? Yes
❏
No
❏
Diagnosis:
History of Illness or Injury:
Name of Referring Physician or Other Source:
For Services Related to Hospitalization (Give Date)
Admitted:
Discharged:
Name and Address of Facility Where Services
Was Laboratory Work Performed Outside
Rendered:
Your Office? Yes
❏
No
❏
Lab Charges:
Policyholder Last Name
No. and Street City or Town State Zip Code Country No. and Street City or Town State Zip Code Country
First Name Middle Initial Policy Number Certificate/I.D. Number
Date of Service Place of Service
CPT Code
Description of Service
ICD-9
Charge
Will You Accept Assignment?: Yes
❏
No
❏
Total Charges:
Provider’s Signature
Date
Tel. #
Print Provider’s Name
Provider’s Address
Fax #
Tax I.D. #
COMPLETE IN DETAIL TO ENSURE PROMPT HANDLING
MAIL TO:
Administrative Concepts, Inc.
994
Old Eagle School Road
Suite
1005
Wayne, PA 19087-
1802
www.visit-aci.com
A
Insurance Company
CLAIM FORM
CMI-Any person who knowingly
knowingly presents false information in an application for
The laws of some states require us to furnish you with the following noces: WARNING. Any person who knowingly:
Alaska:and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading informaon may be prosecuted under state law.
Arizona Arkansas :presents a false or fraudulent claim for payment of a loss or benefit is subject to criminal and civil penales, or specific to AR :presents false informaon in an applicaon for insurance is guilty of a crime and may be subject to fines and confinement in prison.
California: For your protecon California law requires the following to appear on this form:
Any person who knowingly presents false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Delaware:and with intent to injure, defraud or deceive an insurer, files a statement of claim containing any false, incomplete or misleading informaon is guilty of a felony.
District of Columbia:It is a crime to provide false or misleading informaon to an insurer for the purpose of defrauding the insurer or any other person. Penales include imprisonment and/or fines. In addion, an insurer may deny insurance benefits if false informaon materially related to a claim was provided by the applicant.
Florida:and with intent to injure, defraud, or deceive any insurer, files a statement of claim or applicaon containing any false, incomplete, or misleading informaon is guilty of a felony of the third degree.
Idaho and Indiana: and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading informaon (for Idaho) is guilty of and (for Indiana) commits a felony.
Kentucky, New York and Pennsylvania:and with intent to defraud any insurance company or other person files an applicaon for insurance, or files a statement of claim, containing any materially false informaon or conceals, for the purpose of misleading, informaon concerning any material fact thereto commits a fraudulent insurance act, which is a crime, specific to PA: subjects such person to criminal and civil penales and specific to NY: shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violaon.
Louisiana, New Mexico, Texas and West Virginia:presents a false or fraudulent claim for the payment of a loss (or specific to LA, TX and W VA: who knowingly presents false informaon on an applicaon for insurance) is guilty of a crime and may be subject to fines and confinement in state prison, (or specific to NM: to civil fines and criminal penales.)
Maryland:and willfully presents a false or fraudulent claim for payment of loss or benefit or who knowingly and willfully presents false informaon in an applicaon for insurance is guilty of a crime and may be subject to fines and confinement in prison.
New Jersey:files a statement of claim containing any false or misleading informaon is subject to criminal and civil penales.
Ohio:with intent to defraud or knowing that he is facilitang a fraud against an insurer, submits an applicaon or files a claim containing a false or decepve statement is guilty of insurance fraud.
Oklahoma:and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading informaon is guilty of a felony.
Oregon:and with intent to defraud any insurance company or other person files an applicaon for insurance or a statement of claim containing any materially false informaon or con-ceals for the purpose of misleading, informaon concerning any fact material hereto, may be subject to prosecuon for insurance fraud.
Puerto Rico: and with the intenon of defrauding presents false informaon in an insurance applicaon, or presents, helps, or causes the presentaon of a fraudulent claim for the pay-ment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon convicon, shall be sanconed for each violaon with the penalty of a fine of not less than five thousand (5,000) dollars and not more than ten thousand (10,000) dollars, or a fixed term of imprisonment for three (3) years, or both penales. If aggravang circumstances are present, the penalty thus established may be increased to a maximum of five (5) years; if extenuang circumstances are present, it may be reduced to a minimum of two (2) years.
WARNING:
Colorado:It is unlawful to knowingly provide false, incomplete, or misleading facts or informaon to an insurance company for the purpose of defrauding or aempng to defraud the company. Penales may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, in-complete, or misleading facts or informaon to a policyholder or claimant for the purpose of defrauding or aempng to defraud the policyholder or claimant with regard to a selement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Hawaii:Presenng a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
Maine/Washington:It is a crime to knowingly provide false, incomplete or misleading informaon to an insurance company for the purpose of defrauding the company. Penales may in-clude imprisonment, fines or a denial of insurance benefits.
Minnesota:A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Hampshire:Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading
informa-on is subject to prosecuon and punishment for insurance fraud, as provided in RSA 638.20.
Tennessee and Virginia :It is a crime to knowingly provide false, incomplete or misleading informaon to an insurer or insurance company for the purpose of defrauding the insurer or insurance company. Penales include imprisonment, fines and denial of insurance benefits.
