Claim Forms. The Company, upon receipt of a notice of claim will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within fifteen (15) days after receipt of such notice the claimant shall be deemed to have complied with requirements of this Policy as to proof of loss upon submitting, within the time fixed in the Policy of filing proofs of loss, written proof covering the occurrence, the character and extent of the loss for which claim is made.
Claim Forms. The Company, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proof of loss. If such forms are not furnished within fifteen (15) days after the giving of such notice the claimant shall be deemed to have complied with the claim filing requirements of this Contract.
Claim Forms. HMO must require all THSteps providers to submit claims for services paid (either on a capitated or fee-for service basis) on the HCFA 1500 claim form and use the unique procedure coding required by TDH.
Claim Forms. Claim Forms shall be submitted online or by mailing to the Settlement Administrator. The deadline for submitting a valid Claim Form shall be forty-five (45) days from the Notice Date. Valid Claim Forms must include the claimant’s current mailing address, valid email address, and claimant’s unique $Cashtag identifier or the Settlement Administrator’s unique claim ID for the claimant. The Settlement Administrator shall be initially responsible for determining if a claim is valid.
Claim Forms. A claim form can be requested by calling the Member and Provider Service telephone number on the identification card during regular business hours. CareFirst BlueChoice shall provide claim forms for filing proof of loss to each claimant. If CareFirst BlueChoice does not provide the claim forms within fifteen (15) days after notice of claim is received, the claimant is deemed to have complied with the requirements of the policy as to proof of loss if the claimant submits, within the time fixed in the policy for filing proof of loss, written proof of the occurrence, character, and extent of the loss for which the claim is made. When a child subject to a Medical Child Support Order or a Qualified Medical Support Order does not reside with the Subscriber, CareFirst BlueChoice will
1. Send the non-insuring, custodial parent identification cards, claims forms, the applicable certificate of coverage or member contract, and any information needed to obtain benefits;
2. Allow the non-insuring, custodial parent or a provider of a Covered Service to submit a claim without the approval of the Subscriber; and
3. Provide benefits directly to:
a) The non-insuring, custodial parent;
b) The provider of the Covered Services, Covered Dental Services, or Covered Vision Services; or
c) The appropriate child support enforcement agency of any state or the District of Columbia.
Claim Forms. Upon receipt of a notice of claim, we will furnish to the claimant such forms as are usually furnished by us for filing proofs of loss. If claim forms are not furnished within twenty (20) days after the giving of notice, the claimant shall be deemed to have complied with the requirements of this Agreement as to proof of loss upon submitting, within the time fixed in the contract for filing proof of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made. Please note that you are not required to use a claim form to notify us of a claim. When you receive an itemized bill from a hospital, physician, or ancillary provider not contracting with us, you may forward that bill directly to us for processing. Simply indicate the medical record number of the patient on the bill and submit it directly to us.
Claim Forms. (A) In order to receive a Settlement Award, Settlement Class Members must submit a valid Claim Form by the Claim Form Deadline via First Class United States Mail, postage prepaid.
(B) To submit a valid Claim Form, Settlement Class Members must affirm that they meet the requirements set forth in Part A of the Claim Form and one of the requirements contained in Part B of the Claim Form, and that these representations are made in accordance with Part C of the Claim Form. Under the Claim Form, each Settlement Class Member may submit a separate claim for each time the person took non- primary caregiver leave for the birth of a child during the relevant Settlement Class Period for that Settlement Class Member.
(C) In the event any Claim Form is timely submitted but does not contain sufficient information, the Settlement Administrator shall provide the Settlement Class Member with a letter (“Cure Letter”) via First Class U.S. Mail (and email if the Settlement Class Member has provided email to the Settlement Administrator), with an included postage-paid return envelope, requesting the information that was not provided and giving the Settlement Class Member the longer of fifteen (15) days from mailing of the Cure Letter or the Claim Form Deadline (“Cure Claim Bar Date”) to return a properly completed Claim Form. Any Settlement Class Member who fails to respond timely to a Cure Letter will not receive a Settlement Award.
(D) In the event of a dispute regarding the validity of a Settlement Class Member’s Claim Form, the Settlement Administrator shall promptly report the nature of the dispute to Class Counsel and Defendant’s Counsel, who will confer in good faith with the Settlement Administrator in an effort to resolve the dispute. Defendant will be afforded an opportunity to challenge the veracity of information contained in the Claim Form and may submit supporting documentation for any challenges to the Settlement Administrator. If Defendant makes such a challenge, the Settlement Class Member will have an opportunity to respond to the challenge before a determination of the validity of his claim by the Settlement Administrator. If the Settlement Class Member’s claim is not deemed valid, the Settlement Administrator will inform the Settlement Class Member. The Settlement Administrator’s decision on the validity of the claim shall be binding and non-reviewable by the Court.
Claim Forms. Plaintiffs and Lead Counsel will ensure that each claim form contains a copy of the release set forth in paragraph 12 hereof. A claim form shall be signed by each member of the Class or its authorized representative as a precondition to receiving any portion of the Settlement Fund.
Claim Forms. Upon receipt of written notice of a claim for a waiver under this Rider, we will furnish to you a form or forms for filing a proof of occurrence. If we do not furnish such form or forms within fifteen (15) days of receipt of the written notice of claim, you will be deemed to have complied with the requirements as to proof of occurrence upon submitting, within the time period set out in the Written Proof of Occurrence provision below, written proof covering the character and the extent of the occurrence covered by this Rider. You must provide us with written proof of occurrence of the conditions set out in the “Waiver” provision above. You must provide us with such written proof of occurrence:
Claim Forms. 1. To be eligible for the Settlement Benefits, Settlement Class Members must make a qualifying Claim Form submission. A Claim Form submission will be qualifying if it is timely submitted and in conformance with this Agreement. A Claim Form submission may encompass multiple bills or services under an insurance claim (i.e., a claim arising under the same accident, and typically having a unique claim number). However, a separate Claim Form will be required for bills and services rendered under separate insurance claims for treatment to different insureds and/or from different accidents.
2. Claim Forms must be sent by First-Class Mail, postage prepaid, to the Claims Administrator or uploaded to the Settlement Website established and maintained by the Claims Administrator. The Claim Form must be submitted to the Claims Administrator and postmarked no later than one hundred and eighty (180) days from that initial Class Notice mailing date.
