United Schools Associates (USA) and the Assurity Claims Contact Center are available to handle telephone calls from policyholders. The claims contact center can verify coverage to providers, and can answer many questions about policy benefits
There are no claim forms involved for filing wellness benefits. –
However, before calling to file a wellness claim, please compile the following information pertaining to your wellness exam: date of service, procedures and/or tests performed, amount charged, and name and contact information of your medical provider. The procedures covered under your wellness benefit are listed below. Once you have on hand all information to file your claim, please call our Claims Department directly: toll free 1-844-USA-4YOU ext. 2 (1-844-872-4968 ext. 2). Once connected to Assurity’s call center, press 1 and dial. ext. 4484. The claims department is available Monday through Friday 7:00 a.m. to 5:00 p.m. central time.
1.) Group Accident Expense Wellness Benefit rider – pays a benefit when a charge is incurred for a specific test or procedure:
Wellness Benefits:
Annual Physical exam or routine eye exam
Immunizations
Blood screening for triglycerides, cholesterol, HDL, LDL, or fasting blood glucose
*Once per day, up to two per insured per calendar year;
maximum of four for all insured persons combined per calendar year
Tiers 1 & 2
$50 x 2 = $100
$200 for Family
2.) Accident Expense Pro Benefit Rider pays a benefit when a charge is incurred for a specific test or procedure for each of two groups:
$50 per calendar year for each insured category (once for employee and spouse individually, once for children collectively) when a charge is incurred for one of the following after the 30-day waiting period (may vary by state):
- Annual physical
- Blood test and triglycerides
- CA 19-9 (blood test for pancreatic cancer)
- Fast blood glucose test
- Hemoccult stool analysis
- PSA (blood test for prostate cancer)
- Pap smear
- Vision/hearing exams
- Vaccinations (flu shot, pneumonia shot, tetanus shot, MMR, polio vaccine, chicken pox, diphtheria)
$100 per calendar year for each insured category (once for employee and spouse individually, once for children collectively) when a charge is incurred for one of the following after the 30-day waiting period (may vary by state):
- Biopsy for skin cancer
- Bone marrow biopsy and aspiration
- Breast ultrasound
- CA 15-3 (blood test for breast cancer)
- CA 125 (blood test for ovarian cancer)
- CEA (blood test for colon and cervical cancer)
- Chest x-ray
- Colonoscopy
- Flexible sigmoidoscopy
- Mammography
- Serum cholesterol test to determine level of HDL and LDL
- Serum protein electrophoresis (blood test for myeloma)
- Stress test (bicycle or treadmill)
- Thermography
The Wellness rider for the Accident Expense PRO (rider no. R W1110) and HI PRO (rider no. R W1243) and other wellness programs offered by USA, are underwritten by various carriers including but not limited to: Assurity Life Insurance Company, Lincoln, Nebraska. Policy and rider availability, features, and rates may vary by state. Descriptions of benefits are intended only to highlight benefits and should not be relied upon to fully determine coverage.
Wellness Claims:
Benefit available after 30 days from issued date. Have a test or procedure from one or both category groups? Call the USA & Assurity Claim Center – toll free 1-844-USA-4YOU ext. 2 (1-844-872-4968 ext. 2) to process your benefits. Please have the following information on hand; date of service, procedures and/or tests performed, amount charged, and the name and contact information of your medical provider.
The following forms are needed to consider a new claim:
Disability Income Claims:
| Claim Statement | Form # 01-012-02255 |
| Employer’s Statement | Form # 01-013-02255 |
| Attending Physician’s Statement | Form # 01-014-02255 |
| Confidential Information Authorization | Form # 75-500-05055 |
Emergency Accident Rider under the Disability Income Policy:
Copy of the accident report and an itemized billing showing insured’s name, date of service, diagnosis code, procedure code, and billed amount.
Accident Expense Claims:
Copy of accident report Accident Claim Form # 75-010-02283 Itemized billing showing insured’s name, date of service, diagnosis code, procedure code, and billed amount.
Life Insurance Claims:
Please call Assurity at the number listed above to request the forms.
Critical Illness Claims:
Please call Assurity at the number listed above to request the form.
Hospital Indemnity Claims:
Itemized billing showing insured’s name, date of service, diagnosis code, procedure code, and billed amount.
Cancer Claim:
Itemized billing showing insured’s name, date of service, diagnosis code, procedure code, copy of pathology report and billed amount.
To begin the claim process or request the proper forms, contact the claims contact center:
- Email: claimsinfo@assurity.com
- Fax: 1-402-437-4592 or toll free fax 1-800-869-0368
- Mail:
United Schools Associates, Inc. & Assurity Claims Department
PO Box 82533 Lincoln, NE 68501-2533
If the claim form is emailed or faxed as described above, please do not mail the original claim form.
