556 Clay Street Montgomery AL 36104 Team Assure

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com 2017 -2018 CLAIMS FILING PROCESS USING OUR “TICKET SYSTEM” FOR ZERO DEDUCTIBLE STUDENT ATHLETIC / ACTIVITIES ACCIDENT MEDICAL SUPPLEMENTAL BENEFIT PLAN TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com School Claim Filing Instruction Process 1. Download the GAP Notification of Injury Form (NOIF) Claim Submission Form from our site. 2. Read the following form instruction and fill out the form completely. 3. Submit the form on our ticket system or, if you prefer, by fax and mail. TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com School Claim Filing Instructions (Part 1) UPON ACCIDENTAL INJURY: A school representative (coach or principal) should obtain the Notification of Injury Form from your School. Only one form per injury is needed. To be a covered accident, injury must occur during an association/school sponsored and supervised activity, treatment must commence within 30 days of injury by a legally qualified medical doctor, and injury form must be submitted within 90 days of the injury. There is a one year benefit period. TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com School Claim Filing Instructions (continued) 1. Please throw away all older forms and copies. Use the new Notification of Injury Form and this procedure memo to make copies. 2. Read the claim instructions on top of the Downloaded Notification of Injury Form. 3. Part I - Notification of Injury Form - Answer each question completely. To protect the school, have the parent or guardian sign and date line 14. TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com School Claim Filing Instructions (continued) 4. Part II - Notification of Injury Form - Have the parent complete lines 1 through 8 5. Keep a copy for your records. 6. Give a copy of the Parent Instructions sheet to the parent/guardian. 7. Inform the parent to send a COPY of the injury form immediately to the following address: TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com School Claim Filing Instructions (continued) ABT Claims Reimbursement P. O. Box 6133 Montgomery AL, 36106 Phone: 844 -350 -9897 Secure Fax: 334 -649 - 7901 TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com School Claim Filing Instruction (continued) 8. Inform the parent to send copies of itemized provider bills and corresponding explanation of benefits (EOB'S) from the other insurance plans as they arrive. Parent/guardian must understand that this is a secondary plan with a one(l) year benefit period and that they should first file on and follow procedures of any other individual or family medical plans(Private, All- Kids, Champus, Medicare, or Medicaid, etc. ). It is the parent/ guardian's responsibility, not medical providers or school, to submit their form completed properly. TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com HELP DESK INSTRUCTIONS For School Officials and Parent If, after submitting a claim via our ticket system, by mail or fax and you have follow-up questions please submit them by email: info@teamassure. net or by visiting: https: //teamassure. freshdesk. com/support/home Our helpdesk page has a unique SSL Certificate and all information transferred is encrypted with 728 bit security In addition, the system is scanned on a regular basis using PC! Security Scanning from Trust Guard. TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com School Claim Filing Instructions (form sample) A school representative is to fill out the top portion: Part 1 (school report) completely Have the parent/ guardian sign line 14 of part 1 TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com Parent/Guardian Filing Instructions (Part 2) TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com Parent/Guardian Filing Instructions (continued) 1. Read the claim instructions on top of the Notification of Injury Form. 2. PART I - Sign and date line 14 (parent/guardian acknowledgement of receipt) 3. PART II - Complete lines 1 through 8 of the Notification of Injury Form • Send a COPY of the injury form, COPIES of bills, and COPY of explanation of benefits (EOB'S) from the other insurance plans to the following address: TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com Parent/Guardian Filing Instructions (continued) ABT Claims Reimbursement P. O. Box 6133 Montgomery AL, 36106 Phone: 844 -350 -9897 Secure Fax: 334 -649 - 7901 DO NOT DELAY. Send in Notification of Injury Form as soon as injury occurs. TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com Parent/Guardian Filing Instructions (continued) 5. For answers to questions about the status of your claim call: 1 -884 -350 -9897 (Monday – Friday) 9: 00 am - 5: 00 pm CST 6. File on and follow procedures of any other individual or family medical plans (Private, All. Kids, Champus, Medicare, or Medicaid, etc. ). This is a secondary accident medical plan with a one (1) year benefit period. TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com Parent/Guardian Filing Instructions (continued) 7. Send COPIES of bills and explanation of benefits (EOB'S) from the other insurance plans as they arrive. It is the parent/guardian's responsibility, NOT medical providers or school to submit their form completed properly. IMPORTANT: Keep the original for your records. The parent, not a provider, must submit: the Injury Form, EOB's, and provider balance bills to the above address. TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com HELP DESK INSTRUCTIONS For Parent and School Officials If, after submitting a claim via our ticket system, by mail or fax and you have follow-up questions please submit them by email: info@teamassure. net or by visiting: https: //teamassure. freshdesk. com/support/home Our helpdesk page has a unique SSL Certificate and all information transferred is encrypted with 728 bit security In addition, the system is scanned on a regular basis using PC! Security Scanning from Trust Guard. TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com Parent/Guardian Filing Instructions (form sample) A Parent or Guardian is to fill out the bottom portion: Part 2 (Parent/ Guardian report) completely Be sure to sign line 14 of part 1 TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com TEAM ASSURE GAP NOIF FORM To download the latest GAP NOIF form, go to our website at http: //teamassure. net/: look at the top of our webpage and mouse over the FORMS ICON, and click on CLAIMS SUBMISSION (see the site screen shot on the next two slides) TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com Scroll Mouse Over Forms TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com Click on Claims Scroll your mouse Submission down and over and release the mouse on the GAP NOIF Instruction PDF form. Print page 3 of the form. Fill it out completely and submit TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com TEAM ASSURE TICKET SYSTEM Form Submission Process and Explanation TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com TEAM ASSURE TICKET SYSTEM • Our ticket system is used for Electronic Filing of the Claims Form, Explanation of Benefits (EOB’s), Billing Statements, any documentation you need to Submit to our Claims Payer, all you need to do is to scan these documents into your computer then follow the procedures on the next slide to submit to Academic Benefit Trust to pay the claim. TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com TEAM ASSURE TICKET SYSTEM • For claims submission straight to ABT our claims payer via the Ticket System, you will needed to have already download, printed, completely fill-out, and scanned your NOIF form. You may now submit the form by clicking NEW SUPPORT TICKET in our ticket system (Also, be sure to attach any documentation you have received, {i. e. , claims form, EOB's, billing statements, etc. ). Then click on the SUBMIT BUTTON and your claim form and attachments will be submitted automatically to ABT for processing. This will be submitted straight to our claims payer, ABT, and is more secure than sending by fax or mail and has a quicker turn around in processing time for the claim. ** ** The parent, not a provider, must submit: the Injury Form, EOB's, and provider TEAM ASSURE CLAIMS FILING PROCESS balance bills

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com If You have Already Signed Up and are returning to Submit More Documentation or Check the Status of Your Claim, Click on Log-In If You have already Signed Up and need to Submit Other Documentation or want to Check the Status of your Claim Click on Login TEAM ASSURE CLAIMS FILING PROCESS If this is your First Time Logging In, You will have to Signup First so Click on Signup

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com To Signup— Enter your Full Name, here and enter your email address here Then click on Register TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com Once You Have Signed-up, Click On New Support Ticket TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com SUBJECT LINE: Name of Injured Insured (i. e. , John Smith’s NOIF, or EOB’s, or Billing Statements Claim Submission, Dothan City Schools) REQUESTER: Email of Parent of Injured Student or School Representative Representing Parent for this Claim DESCRIPTION: Give as much information as possible (i. e. , I am forwarding in John Smiths NOIF, we do not have the Explanation of Benefits or Billing Statements back from BC/BS or Medicare yet but will forward in as soon as I get them. ) ATTACH A FILE: Attach your scanned NOIF, EOB’s, Billing Statements, & Documentation Attaches Here SUBMIT: Once All Info is Provided Click on Submit Button, You will Receive an email Confirmation Back that Claims Payer has received Submission TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com TEAM ASSURE TICKET SYSTEM • Make Sure that as soon as possible after an accident to a student a NOIF is submitted to our Claims Payer via the Ticket System to start the Claims Process • If you do not have all Explanation of Benefits (EOB’s), Billing Statements, or Required Documentation, once you receive it Repeat the Submission Requirements from Previous 4 slides to Submit the Documentation to our Claims Payer TEAM ASSURE CLAIMS FILING PROCESS

556 Clay Street Montgomery, AL 36104 • Team. Assure. net P) 334 -395 -8000 • F) 334 -395 -80 11 E) info@plannedbenefit. com TEAM ASSURE TICKET SYSTEM • When you receive your email confirmation back from our claims payer that your NOIF has been received and a claims number has been assigned to the injured student, they will include a link for you to go in and set up a password so you can keep up to date on the status of your claim until you receive your claim payment settlement • The check will be made to the parent or guardian, not the physician, clinic, or hospital TEAM ASSURE CLAIMS FILING PROCESS