| Lefebvre Insurance, LLC |
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To obtain a claim form:
| Please contact: | ||
| Lefebvre Insurance at (800) 451-9668 |
Using the form obtained from above, or from the brochure file that you printed if Voluntary
coverage was purchased......
coverage was purchased......
- Part I, or Part A, of the form is to be completed by the School. Parts II and III, or Part B,
of the claim form are completed by the Parent/Guardian. (If filing a claim under the
Voluntary 24-Hour coverage, then the Parent/Guardian must also complete Part I, or
Part A of the claim form) Please refrain from using abbreviations when answering
questions.
- Make sure that ALL questions are answered, and that all required signatures are
provided. Incomplete forms may delay claims processing.
- Submit the completed claim form to the claims office indicated on the form. Only one
claim form needs to be submitted for each accident.
- Inform all providers of service that there is additional insurance coverage through the
School, giving them the mailing address and telephone number of the claims office
indicated on the claim form. If requested, the coverage's policy number can be
obtained by contacting the claims office, or by contacting Lefebvre Insurance.
- Submit your claim expenses to your other insurer. When you receive the Explanation of
Benefits statement (EOB) from your primary carrier, send it to the address on the claim
form along with the corresponding itemized bills. You must submit itemized bills, as
receipts and balance due statements will not be processed. Standard itemized bills
include:
- 1) UB-04 or UB-92 (used by Hospitals)
2) HCFA-1500 (used by non-Hospital providers)
3) ADA J430 or J434 (used by dental providers)
- Please contact the claims office by calling the number on the claim form if you would
like to check the status of your claim, or if you have any questions on how your claim
was processed, or how the benefit was paid.
| BELOW IS A GENERAL OVERVIEW OF THE CLAIMS PROCEDURE |