Your Guide to GEOSM Group - International Health & Travel ...following these guidelines, you’ll be able to access IMG quickly & easily. Fast, efficient availability when and where

Your Guide to GEOSM GroupThe Global Employer’s Option SM

W W W. I M G LO B A L . C O M

W W W . I M G L O B A L . C O MYour Guide to GEOSM GroupPage 2 of 23

Table of ContentsWelcome to GEO Group � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1

The IMG Advantage � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2

Getting the Most from Your Plan � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 3

Customer Care Contact � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4

24-Hour Services � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 6

IMG Travel Intelligence � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7

Medical Concierge Service � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7

Universal Rx � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7

Precertification � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 8

Claims Procedures � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 9

Definitions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 11

Sample Claim Form � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 12

Explanation of Benefits (EOB) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 16

Frequently Asked Questions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 19

http://www.imglobal.com

Your Guide to GEOSM Group Page 1 of 20

W W W . I M G L O B A L . C O M

At International Medical Group® (IMG®), our team of professionals is available to assist you with your medical needs should they arise. In addition to this guide, you will find the following helpful items enlosed in your insurance packet:

International Medical Group® (IMG®)2960 N� Meridian St�, Indianapolis, IN 46208Telephone: 1�800�628�4664

or 1�317�655�4500Fax: 1�317�655�4505

Email: insurance@imglobal�com

Please take a few minutes to review this guide� It contains general information about how the GEO Group plan works and can assist you in getting the most out of your benefits� For a complete description of your plan benefits, please refer to your Certificate Wording�

Welcome to GEO GroupAs managing

general underwriter and insurance plan

administrator, we would like

to thank you for making GEO Group your international insurance choice.

1. Declaration of Insurance The declaration includes specific provisions. We recommend that you review these documents closely and notify IMG or your insurance producer if you have any questions. Your complete Declaration of Insurance includes the following:

Declaration Page: Contains your personal identification information as well as certain terms of your coverage, including certificate number, effective dates, and deductible chosen.

Certificate of Insurance: Contains a complete outline and certification of coverage under the Master Policy, including definitions and other provisions that are intended to help you understand the various terms and conditions which apply to the coverage you have purchased, including benefits, exclusions, eligibility requirements, and limitations.

2. Identification Card Please keep your identification card with you at all times and present it to your healthcare provider if/when you seek medical treatment. Your identification card contains important telephone numbers for 24/7 service and precertification purposes (please refer to the applicable provisions of your Certificate of Insurance for precertification details). Your provider may offer to precertify for you, however, it is ultimately your responsibility to see that the appropriate requirements are met.

3. MyIMG (myimg.imglobal.com/member) InformationReview information about this powerful 24/7 online member portal available for you to view your coverage, print ID cards, submit claims and precertification online, review claim status and EOBs, and locate providers, among many other tools.

4. Medical Concierge Services Information:In the event that you are in need of a non-emergency medical procedure in the US, this service can help you locate a facility that provides the quality care you need in the most cost-effective setting.

5. Universal Rx Discount Savings Card Discount savings card that can be used at participating pharmacies in the USA.

mailto:insurance%40imglobal.com?subject=

Page 2 of 20


The IMG Advantage

IMG’s HeadquartersIndianapolis, Indiana USA

Since 1990, IMG has provided global benefits and assistance services to millions of members in nearly every country. We’re committed to being there with our members wherever they may be in the world, delivering Coverage Without Boundaries®. With 24/7 medical management services, multilingual claims administrators, and highly trained customer service professionals, IMG is confident in its ability to provide the products international members need, backed by the services they want.

FINANCIAL STABILITY.Owned by Sirius International Insurance Group —an ‘A’ rated, multibillion global enterprise— IMG offers the financial security and reputation demanded by international consumers.

ACCESSIBLE TECHNOLOGY.Log on to the secure, 24-hour online portal, MyIMGSM, to submit and view your claims, manage your account, search for providers, live chat with representatives and more.

INTERNATIONAL EMERGENCY CARE.When you’re away from home and a medical emergency occurs, you may not be able to wait for regular business hours. With our on-site medical staff, you have 24-hour access to highly qualified coordinators of emergency medical services and international treatment.

GLOBAL SUPPORT. With offices and partners across the globe, IMG provides the support you need, when you need it. In fact, it is our corporate mission to be there to protect and enhance your health and well-being.

SERVICE WITHOUT OBSTACLES.With a team of international, multilingual specialists, we are accustomed to working in multiple time zones, languages and currencies. Our global reach means we can work without barriers.

INTERNATIONAL PROVIDER ACCESSSM (IPA).In addition to the expansive UnitedHealthcare PPO network available for treatment received within the US, our proprietary IPA network of more than 17,000 accomplished physicians and facilities allows you to access quality care worldwide. Our direct billing arrangements can also ease the time and upfront expense at select providers.



Getting the Most from Your Plan

f Know your plan benefits. Take the time to review your Certificate of Insurance.

f Understand your benefits with regard to any specific benefit waiting periods and pre-existing medical conditions.

f Know the preauthorization and precertification requirements in order to avoid having your benefits reduced.

f Manage your account online through MyIMGSM. Access your account information 24/7/365 from anywhere in the world.

f When you don’t understand your medical plan, contact IMG’s Customer Care department via phone, email, mail, or live chat.

f Keep your medical identification card in a safe place.

f When you go to the doctor, hospital, clinic, lab, or other facility for medical services, be sure to take your IMG medical identification card.

f When receiving medical care outside of the USA or Canada, minimize the paperwork and upfront expenses by choosing a direct billing provider from IMG’s International Provider AccessSM (IPA) database.

f When receiving medical care in the USA, reduce your out-of-pocket costs by choosing a provider from the UnitedHealthcare Options network.

f When needing prescription drugs in the USA, take advantage of the IMG member discount program through Universal Rx.

f Submit and keep track of your claims. Submit and check the status of your claims via MyIMG.

f After you file a medical reimbursement GEO Group Claim Form with IMG, you’ll receive an Explanation of Benefits (EOB). Read the EOB carefully as this is a detailed record of how your claim was processed.

Worldwide coverage,

multilingual capabilities,

international claims

specialists, & access to IMG

from anywhere at anytime—all

designed to give you

Coverage Without

Boundaries�

Your Guide to GEOSM GroupPage 4 of 20


Customer Care Contact

US SERVICE CENTER CONTACT INFORMATION

Phone: 1�800�628�4664 (USA & Canada) 1�866�677�4500 (from the Bahamas) 1�317�655�4500 (local)

Fax: 1� 317�655�4505Email: customercare@imglobal�comWebsite: imglobal�com

CALLING IMG

When you call IMG directly, you will hear a menu of options� Press zero to connect with the operator� Other important selections include:

1 – Claims information, eligibility inquiries, verification of benefits, or provider information 2 – Precertification or medical concierge service 3 – Emergency assistance

IMG operates Customer Care Call Centers in the US & UK to assist you with questions & emergency needs. By following these guidelines, you’ll be able to access IMG quickly & easily.

Fast, efficient services and availability when andwhere you

need it.

IMG can be contacted 24 hours a day for emergency services, medical evacuations and precertification� A toll-free phone number is also available in the USA, Canada, and the Bahamas�

Page 5 of 20


ADDITIONAL WAYS TO CONTACT IMG

Non-emergency related inquires may be best handled utilizing one of the following methods:

EMAIL

Please send your inquires to the following email addresses:

� Claims and provider inquires:customercare@imglobal�com

� All other inquires: insurance@imglobal�com

Access to worldwide,

quality healthcare

and IMG’s

superior customer service.

LIVE CHAT

During business hours you can chat directly with a Customer Care Representative via Live Chat� Simply visit myimg.imglobal.com and click on the “Live Help” icon to send a message� You’ll be asked to provide your certificate number and date of birth� Once the information is entered, you can begin your conversation�

mailto:customercare%40imglobal.com?subject=

mailto:insurance%40imglobal.com?subject=

Page 6 of 20


To help enhance your global experience, we provide you with an assortment of interactive services through a secure, user-friendly website� Service at your fingertips anytime, anywhere—that’s what MyIMG provides� MyIMG is our proprietary online service that allows you to access information and manage accounts, 24 hours a day, seven days a week, from anywhere in the world�

While our service centers are always available to handle emergencies, MyIMG gives you immediate access to a wealth of information about your account, and can help manage routine areas to save time when you need it most� A few quick and easy features that might be beneficial when you’re on the move include:

MyIMG is easy to use and provides 24-hour secure access to your account� Follow these easy steps to gain access to your information anytime you need it�

1. Go to imglobal.com/member 2. As a first time user, follow the login instructions link and proceed to the New User Registration3. Have your certificate number or insured ID ready4. Follow steps 1-4 as instructed online

24-Hour Services

� Submit & check status of a claim � Obtain certificate documents � Retrieve explanation of benefits

� Initiate precertification � Request ID cards � Search for physicians through our networks

For travelers in the US, the UnitedHealthcare Options network is a longstanding reputable tier 1 network that gives you more access to more doctors and services, including:

� Over 895,000 physicians � 5,600 hospitals in the US � Retail urgent care facilities � A streamlined claims process

International Provider AccessSM

Travelers outside of the US can also enjoy access to quality healthcare worldwide with our proprietary IPA network that includes:

� Over 18,550 physicians and facilities � Direct billing arrangements that minimize time and

upfront expense

EXTENSIVE NETWORK ACCESS

MEDICAL MANAGEMENT SERVICES Access to quality healthcare is critically important when faced with a medical emergency abroad� To coordinate care and provide US and internationally based medical management services, IMG formed a URAC-accredited on-site division devoted entirely to medical management�

From routine medical care and checkups to complex case management and emergency medical evacuations, IMG is there for you� We are committed to consumer protection and empowerment, quality operations, and regulatory compliance� This translates into better care for you—around the world, around the clock�

http://imglobal.com/member



Universal RxThis is a discount savings program available to all GEO members� This program allows card members to purchase prescriptions at one of over 35,000 participating pharmacies in the US and receive the lower of 1) Universal Rx contract price or 2) The pharmacy regular retail price�

This discount program is not insurance coverage� It is purely a discount program to purchasers of GEO Group� Use of the discount card does not guarantee that prescribed medication is covered under the insurance benefit plan�

Please see the card included in your fulfillment kit�

The IMG Travel Intelligence app gives you the tools and information you need to stay informed and minimize risk when away from home� This standalone mobile app provides 24/7 support to keep users up-to-date about global developments no matter where they are in the world�

IMG Travel Intelligence allows you to:

� Access detailed intelligence for 200+ countries � Receive immediate assistance during a crisis via the in-app emergency hotline � Stay informed of travel disruptions such as airline delays & cancellations � Locate hospitals, police stations, & other safe haven information, including local emergency phone numbers � Access pre-trip checklists, including reminders to prepare & store travel documents

IMG’s Medical Concierge helps you make an informed decision when seeking medical care within the US Whether you’re seeking care in a local facility or an unfamiliar location, the quality of care you are receiving is a primary concern� Our Medical Concierge Service is designed to provide you critical information on provider ratings, treatment outcome, and cost of care prior to receiving medical treatment� Your personal Medical Concierge will review your specific non-emergency medical condition and provide you with complete information on provider ratings, past outcomes, and general costs�

In addition, when you use this service, your deductible will be reduced by 50 percent (up to $2,500), and any coinsurance amount will be waived for Eligible Medical Expenses covered under your GEO Group Insurance� To take advantage of this service, simply notify the Medical Concierge that a procedure is necessary�

Note: Due to the high level of data required for this service, Medical Concierge Service is restricted to facilities within the US

Medical Concierge Service

IMG Travel Intelligence



PrecertificationPrior to receiving treatment, you may need to contact IMG to precertify your treatment and/or for verification of benefits� Precertification means contacting IMG’s utilization management and review company to receive a determination of medical necessity for the proposed treatment or services� It’s important to note that precertification is only a determination of medical necessity, not an assurance of coverage, verification of benefits, or a guarantee of payment� Precertification may be undertaken by you, the doctor, a hospital administrator, or a relative�

VERIFICATION OF BENEFITS

Verification of benefits is the process of verifying your general coverage and the available benefits under the plan� You may do this by contacting IMG’s Customer Care department whether or not your treatment or services require precertification� Verification of benefits is not a guarantee of payment or assurance of coverage, and all medical expenses must meet eligible payment guidelines in accordance with the terms and conditions of the plan� While precertification and verification of benefits are separate determinations, both are made in reliance on the completeness and accuracy of the information provided by you and your healthcare providers to IMG�

The following must always be precertified for medical necessity by the Company through the Plan Administrator before admission or receiving the treatments and/or supplies:

� Chemotherapy

� Extended Care Facility

� Home Healthcare

� Care in an extended care facility

� Home nursing care

� Inpatient Hospitalization

� Radiation Therapy

� Surgery or Surgical Procedure

� Transplant

See the Certificate Wording provided in your fulfillment kit.

Page 9 of 20


Claims ProceduresWhen you receive treatment, original itemized bills must be received by IMG within 180 days from the date of service� As a courtesy, claims may be paid in selected alternate currencies by electronic bank wire� Please see the GEO Group Claim Form for more information and conditions of this service�

SUBMITTING YOUR CLAIM & RECEIVING PAYMENT

The consideration process begins when the Insured Person or group administrator submits a claim form for benefits under this insurance to the Company�* The following items must be submitted by or on behalf of the Insured Person to be considered a complete Proof of Claim eligible for consideration of coverage:

� A duly completed, timely submitted, signed claim form & authorization of release of information � All original itemized bills & statements of services rendered from physicians, hospitals, & other healthcare or medical service

providers involved � All original receipts for any costs, fees, or expenses incurred or paid by or on behalf of the Insured Person with respect to the

claim, including all original cash & credit card receipts

The Insured Person and/or physician, hospital, and other healthcare and medical service providers and suppliers have 180 days from the date a claim is incurred to submit a complete Proof of Claim� The processing of submitted claims may be delayed or coverage denied due to an incomplete Proof of Claim or failure to submit Proof of Claim�

We always recommend that you take time to practice the following steps in the claim process:

� Read all documents provided at the time of enrollment prior to seeking medical treatment � Understand which services & procedures require precertification prior to treatment so your benefits will not be reduced � Present your IMG ID card to all medical providers at the time of treatment � Complete a claim form once services have been rendered

*Online claim submission via MyIMG www.imglobal.com/member

Please remember to submit your original

itemized bills and receipts as soon as you receive them. Do not hold them

until the end of the year. IMG will apply eligible medical

expenses to your deductible and coinsurance throughout

the year.

CLAIM FILING ALTERNATIVES

Direct Payment to ProvidersIn many cases, IMG works with the hospital or clinic as an accommodation, including those outside the independent PPO, for direct payment of eligible medical expenses on your behalf� To be eligible to have a claim paid in this fashion, you or the provider must complete a GEO Group Claim Form and submit it with original itemized bills� In this case, you will be responsible for direct payment of your deductible, coinsurance amounts, and non-eligible expenses and charges�

ReimbursementIf you have received treatment and need to be reimbursed for out-of-pocket medical expenses, complete the claim form and submit your original itemized bills and paid receipts within 180 days� We will reimburse your eligible medical expenses after applying the deductible and coinsurance, subject to the terms of the plan�

http://www.imglobal.com/member

Page 10 of 20


EXPEDITE YOUR CLAIM

The following are some tips to help expedite your claim and improve the overall turnaround time:

Note: Failure to comply with supplying additional information within 60 days of the original request may result in the claim being closed for lack of response.

� Submit your claim online via MyIMG imglobal�com/member

� Submit a new claim form for each family member AND each new medical condition being treated

� Complete the form in its entirety� Be descriptive in regards to services the doctor performed, past medical history, date the condition and/or symptoms were first experienced, and addresses of prior physicians� Remember, if a question applies to your particular situation, please answer it

� Even though we can process claims in other languages, when possible, please provide translations in English for charges being submitted

� Keep copies of all forms submitted to IMG� We cannot guarantee your submission will always make it to our offices via the postal service

� Claims submitted via fax and email can only be accepted when they are clear, legible, and do not appear to be altered

� When submitting prescription drug charges for reimbursement, we require more than a cash register receipt� Please forward information that lists your name, date of service, quantity dispensed, price, prescribing physician, and name of pharmacy� To help the process, it’s most helpful if you affix any loose paper receipts to a full piece of paper

� If requesting a wire transfer, we must have complete banking information on file before we can honor that request

� If you are submitting claims on behalf of a dependent minor child and wish for the reimbursement to be sent to the parent or guardian, that request needs to be added to the claim form so special handling may be arranged

� Provide an email address where you can be contacted� Resolution by email is much faster than regular mail

� If a claim is pending for additional information and a form is attached to the Explanation of Benefits you receive, promptly complete the form and send it back to IMG




DefinitionsAnnual Maximum: The total dollar amount your plan will pay over an annual period�

Benefit Maximum: The total dollar amount your plan will pay for a particular service or treatment�

Claimant Form: This is a form that is completed by you or your medical provider, and provides details of the medical condition and services that were given to you along with the costs�

Coinsurance: If applicable, this is the percentage you pay after you have paid your annual deductible and IMG has paid its share of a medical claim�

Covered Service: Any medical service for which your plan will allow benefits� Common examples are doctor office visits, hospitalization, emergency medical care, lab tests and X-rays to find the cause of symptoms, and surgery to treat a covered medical service�

Deductible: The deductible accumulates over the course of the calendar year and is the amount (if applicable) that you must pay before most services are payable under your insurance plan� Some benefits are not subject to the deductible and are considered “First Dollar” benefits�

Exclusion: A medical service that is not covered by the insurance plan�

Lifetime Maximum: The total dollar amount your plan will pay for the entire time you are enrolled in the insurance plan�

Maximum Benefits: The maximum amount the health insurance plan will allow or pay� There are several types of benefit maximums and your plan may or may not have them�

With IMG, you

have access to

a network of

hundreds of thousands

of physicians

and privately

owned and

operated

hospitals.



Sample Claim Form1. Claimant/Patient Information

This is the name and personal information about the person who incurred the claims�

2. Primary InsuredThis is the covered employee’s name and personal information�

3. Claims Correspondence Address: This contact information will assist IMG when we need to contact you regarding this claim�

4. Group Number and ID This is your employer’s group identification number and your personal identification number which is listed on your identification card�

5. Other InsuranceThis information is required if the claimant/patient is covered by another insurance plan�

6. Part B: Claims Information General information about your claim�

7. Part C: Treatments received & paid / reimbursement requested Detailed information about your claim�

8. Part D: Claims Reimbursement – Alternate Payee Request Must be completed by parent or guardian if claimant/patient is under age 18, and/or an alternate payee may be elected to receive payment other than the claimant/patient or medical provider� Example: An employer has paid the provider on behalf of the employee and is seeking reimbursement.

9. Wire Transfer RequestInformation required to reimburse funds via wire transfer�

10. Authorization - ClaimsTo be completed and signed by the claimant/patient (must be signed by parent or guardian if claimant/patient is under age 18)�

11. Authorization - PaymentTo be signed when payment is to be sent to the provider, not to the claimant/patient (must be signed by parent or guardian if claimant/patient is under age 18)�

12. Contact Information for the IMG Claims DepartmentClaims can be sent to either the USA or European Service Centers�

On the following

two pages there

is a sample GEO

Group Claim

Form. One has

been included in

your fulfillment

kit. Please take a

moment to review

the key terms

highlighted on this

sample.

Page 13 of 20


IMG Claim Form

Page 1 of 4


In order for this form to be a valid proof of claim, you must attach the original documents and make certain that documentation is legible, indicates patient’s name, date of service, diagnosis, procedure and/or type of service along with the itemized charges� Failure to submit an accurate, completed form will result in processing delays� The insured has a limited time frame in which to submit a complete proof of claim, and IMG (the “Company”), at its option, may deny coverage for proof of claim submitted thereafter, for incomplete proof of claim and/or failure to submit a proof of claim�

Claim Form & Authorization FilingInstructions

PART A. To be completed by the claimant for all claims

Claimant/Patient Name:(As it appears on ID card) Passport/Visa Number:

Male Female Date of Birth: ___/___/___ (MM/ DD/YYYY)

Claimant’s Relationship to Primary Insured: Self Spouse Child Other

Name of Primary Insured:(As it appears on ID card) Insured ID #:

Male Female Date of Birth: ___/___/___ (MM/ DD/YYYY)

Home Country Address:

Current Address: City:

State: Postal Code: Home Phone: Work Phone:

Communications should be sent via email to:

Are you a full-time student? Yes No Group #:

If yes, please provide the following information:

Name of School:

Street Address: Phone:

City: State: Postal Code: Country:

Email:

How many months of the year are you residing in the U�S�?

ALTERNATE PAYEE INFORMATION

Name:

Street Address: Phone:

City: State: Postal Code: Country:

Email:

If claimant is or may be covered by other coverage, complete the items below�

Name of Primary Insured: (as it appears on ID card) Date of Birth: ___/___/___ (MM/ DD/YYYY)

Insured mailing address: City: State: Postal Code:

Name of other carrier: ID # for other coverage:

Type of other coverage: Carrier Phone number:

Carrier address: City: State: Postal Code:

Name of employer: Employer Phone number:

Employer address: City: State: Postal Code:

Please print legibly and complete ALL SECTIONS of this form� Mail, fax, or email completed form to: Address: International Medical Group, Inc� Claims, P�O� Box 9162, Farmington Hills, MI 48333-9162 USA, Call: +1�800�628�4664 or outside U�S� +1�317�655�4500; Fax: +1�317�655�4505Email: customercare@imglobal�comwww�imglobal�com

1.

2.

3.

4.

5.

Page 14 of 20


6.

IMG Claim Form

Page 2 of 4


PART B. To be completed by the claimant for each new condition, injury, or illness (if you need additional space, please attach a separate sheet)

1� When did the fi rst symptom of this condition begin? State the exact date if possible: ___/___/___ (MM/ DD/YYYY)

2� How did the condition begin? State fully all symptoms and describe the condition in detail after it began� For accidents, include pertinent details such as how, when and where the accident occurred�

3� Have you ever had or been treated for this type of condition before? Yes No

4� List all the names and addresses of the providers you have seen for this condition�

5� What sicknesses, diseases, illnesses, injuries, or other physical, medical, mental or nervous disorder, conditions, or ailments have you experienced during the last fi ve years? Please provide the name and/or description of each condition, dates of treatment, and name and address of the facility and/or attending physician(s)�

6� Is this condition the result of an accident, injury, or illness:

a� Related to employment? Yes No

If yes, are you applying for Worker’s Compensation benefi ts? Yes No

b� Involving a motor vehicle or another person’s actions? Yes No

If yes, list the names of parties involved, insurance carriers and policy numbers�

c� Was a report fi led with any governmental or investigating entities? Yes No

If yes, please identify the department and the address where it was fi led�

d� Was this accident related to an organized or sanctioned athletic activity, Yes No

involving regular or scheduled games and/or practice? If so, was an accident report fi led with the sports coordinator? Please provide a copy of any related accident reports�

e� In the event you have hired legal counsel, please provide IMG with the complete name, address and telephone number of the attorney�



7.

IMG Claim Form

Page 3 of 4


PART C. Complete for all treatment received outside of the United States�

Date of service(MM/ DD/YYYY) Provider

What type of service and/or name of drug

provided?

What was the illness/injury?

City/country

Type of currency

paid or billed

Total chargepaid or billed

Converted to U�S� funds Offi ce use only

Account Holder’s Name:

Bank Name:

Bank Address: City: Country:

Currency of reimbursement: Bank 9 digit ABA number—U�S� banks:

Bank 8 or 11 digit SWIFT code—non-U�S� banks: Sort code:

Bank account number: Bank IBAN:

Intermediary Bank Details (if applicable):

Name of intermediary bank:

Intermediary bank SWIFT code: Intermediary bank account number:

PART D. PAYMENT DETAILS (Checks will only be issued to a United States address�)

Make payment to the provider

Make payment to primary insured Reimbursement method Bank ACH or wire transfer (complete below) Check

Make payment to alternate payee Reimbursement method Bank ACH or wire transfer (complete below) Check

8.

9.



IMG Claim Form

Page 4 of 4


If this form is signed by someone other than the patient or parent, such as a personal representative, legal representative or guardian on behalf of the patient, submit the following: a copy of a healthcare representative form, power of attorney, a court order or other documentation showing custody, or other legal documentation showing the authority of the legal representative to act on the patient’s behalf�

PART E. AUTHORIZATION—to be completed by the claimant for all claims.I verify that all information contained in this form is true, correct and complete to the best of my knowledge� I authorize any health plan, health care provider, health care professional, MIB, federal, state or local government agency, insurance or reinsuring company, consumer reporting agency, employer, benefi t plan, or any other organization or person that has any records or knowledge of my health, has any information available as to diagnosis, treatment and prognosis with respect to any physical or mental condition and/or treatment of me, and any non-medical information about me, to disclose my entire medical record, fi le, history, medications, and any other information concerning me and to give any and all such information to my agent of record and authorized representatives of Company, IMG, and their affi liates, and subsidiaries� Individuals have the right to refuse to sign the authorization without negative consequences to treatment or plan enrollment, except IMG will not be able to administer claims, determine benefi t eligibility, or issue payments� The authorization is valid for the term of the insurance contract or plan under which a claim has been submitted�

I understand that I have the right to receive a copy of this authorization upon request and revoke the authorization at any time in a written communication to IMG� A copy of this shall be as valid as the original� I acknowledge and understand there is the potential for the information to be subject to re-disclosure by the recipient and to no longer be protected by applicable privacy and confi dentiality laws�

Any person who knowingly presents a false or fraudulent claim for payment of a loss of benefi t or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fi nes and confi nement in prison.

Print Name of Insured: __________________________________________________________________________________________________________

Signature of Insured/Legal Representative: X_________________________________________________________ Date: ___/___/___ (MM/ DD/YYYY)

AUTHORIZATION:

I authorize payment of any benefi ts for eligible medical expenses to the provider or other supplier of services which is entitled to payment of the attached bills�

Signature of the Insured/Legal Representative: X_____________________________________________________ Date: ___/___/___ (MM/ DD/YYYY)

Version 0719IN01200799A190731

If needed you can overnight packages to following address:2960 North Meridian Street, Indianapolis, IN 46208

10.

11.

12.

The EOB is a summary of how your claim was processed. Take a moment to review the key terms highlighted on this sample EOB (page 18).

If you have a question about your EOB, please contact the IMG Customer Care department.

Explanation of Benefits (EOB)

IMG is transitioning our claims Explanation of Benefits (EOBs) to a new format in order to provide you better claims information that’s easier to understand� We’ve created this document to describe the new format, including details on each section� Actual EOBs may vary based on the type of coverage you have�



1

2

3

1. Explanation of Benefits (EOB) – IMG sends you a claims statement anytime we process a claim� It includes the name and address of the insured member, patient, or alternate payee� The document details how the benefits cover the cost of a service from a provider and what is owed by the patient� The EOB is not a bill

2. Customer Service Information – This sections shows the date that the EOB was prepared and contact information for IMG’s customer service department

3. Color Key – Items in blue show the plan’s responsibility� The member’s responsibility is shown in green

54

7

6

8

10

1221 13 14 15 16 17 18

22

239

11

19

20

4. Member ID Number – This is the identification number that IMG uses to keep track of member’s claim activity in our claims system

5. Claim Number – This number is assigned by IMG’s claims system when the claim is processed

6. Provider and Patient Information – This section includes the provider’s name, group name, member’s name and member’s account number (assigned by the provider)� For member-paid claims, the provider name will be “Member Paid”

7. Date of Service – The date(s) the member received treatment

8. Service Code – The type of services or products the member received from the provider

9. Total Charge – The full amount billed by the provider to the plan

10. Not Covered – The portion of the total charge that was not covered or eligible for payment under the plan

11. Reason Code – A code that corresponds with the Remark Code description

12. Discount Amount – The amount saved by using an in-network provider

13. Covered by Plan – The portion of the charges eligible for benefits

14. Less Deductible – The deductible is the amount for which the member is responsible during each period of coverage

15. Less Copay – A set amount that the member pays for certain covered services, such as office visits or prescriptions� Copays are usually paid at the time of service

Page 18 of 20


16. Amount Subject to Coins – The total benefit amount subject to coinsurance

17. Paid At – The actual coinsurance percentage

18. Less Patient Share of Coins – The amount of the member’s share of the coinsurance

19. Payment Amount – The amount paid by the plan for each claim line

20. Column Totals – The total of each of the columns

21. Total Patient’s Responsibility – Total amount that the member is responsible for paying after the plan benefits have been applied

22. Other Credits or Adjustments – Any adjustments, credits, or previous payments applied

23. Total Payment – The total amount paid by the plan

25

24

29

2728

26 30

24. Service Code Description – An explanation of the procedure (service) codes listed on the claim� These codes describe the services that were rendered by the provider

25. Remark Code Description – An explanation of the remark code used on the claim

26. Copy of the Front of the Voided Check Image

27. Additional Information – Applicable appeal language and/or general information

28. Payment Details – Explains to whom the payment was issued, the check/wire number, and amount

29. Accumulators/Amount – Amount applied to deductible or out-of-pocket amounts

30. Copy of the Back of the Voided Check Image

Page 19 of 20


Frequently Asked QuestionsQ: How do I enroll my newborn child?A: In order for a newborn dependent child to have coverage from the moment of birth, the following requirements must be met: 1� The maternity must be covered under the plan; and 2� A completed and signed enrollment form adding the newborn as a dependent of the covered employee MUST be received by IMG no later than 30 days following the date of birth

Q: How do I access my personal account information on MyIMG?A: 1� Go to myimg.imglobal.com/member 2� As a first time user, follow the Login Instructions link and proceed to the New User Registration 3� Have your certificate, group number, or Insured ID ready 4� Follow steps 1-4 as instructed online 5� Note: For employees insured under an employer group sponsored plan, your group plan administrator must

first go through the New User Registration process with IMG’s Underwriting department before you’ll be able to access MyIMG�

Q: What types of assistance does IMG provide members?A: � 24-hour online access to MyIMG � Toll-free 800 number from USA/Canada � 24-hour availability for emergency services, medical evacuation, and precertification � On-site, physician-directed emergency medical services and large claim management � Ability to reimburse claims directly to you or the provider in most major currencies via wire transfer � Foreign language translation for claims

Q: Do I need to carry my ID card with me at all times?A: Yes, it’s important that you have the medical telephone information available in the event it is needed for you or others�

Making a copy, as you would do with your passport, is recommended�

Q: What must I do before a hospital admission or surgery?A: Precertification is required for hospital admissions and all surgeries� Prior to receiving treatment, you or a medical

provider need to contact IMG to precertify your treatment�

Q: What must I do if my spouse or I become pregnant?A: Contact IMG as soon as possible in order to begin the precertification process, but always within the first 60 days of the pregnancy�

Q: What happens if I have an emergency hospital admission and don’t have time to precertify?A: In the event of an emergency hospital admission, prenotification/precertification must be done within 48 hours after the admission, or as soon as is reasonably possible� IMG must be contacted by you, a relative, the doctor or the hospital�

Q: How are claims processed?A: Your eligible claim will be processed for payment when we have received all needed information� Your claims payment can be delayed if additional information is needed from you and/or your provider� If additional

information is needed, IMG may request your medical records from your provider� Always request copies of your medical records from your provider� If no proof is provided when requested by IMG, your claim request may not be processed�

Q: When should I submit a claim?A: Claims must be submitted to IMG within 180 days from the date of service�


Page 20 of 20


Q: What is required to accurately complete a claim form?A: It’s important to submit the fully completed GEO Group Claim Form along with itemized bills, statements, an invoices

for services and supplies you have received�

Q: What typically delays a claim from being paid?A: The most common problems are missing information such as: � Incomplete claim form � Missing itemized receipts � If related to a pre-existing condition, a prior Certificate of Credible Coverage will be required

Q: What if I want to designate someone to act on my behalf?A: If you wish to have someone act on your behalf, IMG requires that a Privacy and Confidentiality Statement be signed by the insured person or guardian� This form is part of the claim form� The Customer Care department will not discuss any information with the designated person, unless the completed form is on file�

Q: Will IMG pay directly to providers?A: In many cases IMG works directly with the hospital or clinic as an accommodation, including those outside the USA PPO network, for direct payment of eligible medical expenses on your behalf� To be eligible to have a claim paid in this manner, you or the provider must complete a GEO Group Claim Form and submit it with copies of your itemized bills� If applicable, you will be responsible for direct payment of your deductible, coinsurance amounts, and non-eligible expenses and charges�

Q: What happens if the provider bills me before IMG pays the bill?A: Many providers send copies of bills to the insurance company and to the patient� If you receive a bill after receiving treatment from a provider, please contact IMG’s Customer Care department� The provider most likely sent the bill to IMG and the bill will be paid soon� Help us avoid duplicate payments by allowing IMG to make payments to providers on your behalf�

Q: How do I submit a claim?A1: If you’re outside the USA and you pay for medical treatment, complete a GEO Group Claim Form, attach copies of the original itemized bills and paid receipts, and mail, email, or fax to IMG or submit your claim online at imglobal�com/member�

A2: If you receive a bill from a PPO Provider while in the USA, please send it to IMG� If you pay your bill directly to the provider, you may not receive a PPO Provider discount� Note: claims must be filed within 180 days from the date that the eligible expenses were incurred�

0919CM00500864A191024



Documents

Your Guide to GEOSM Group - International Health & Travel ...following these guidelines, you’ll be able to access IMG quickly & easily. Fast, efficient availability when and where