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SMC|Enrollment Development|International Education Center|Student Health Service

Student Health Service

Medical Insurance 2013-2014

Student Health Center

 

The Covered Student must first use the services of Student Health Services (the Health Services Center and Psychological Services) where either treatment will be administered or referral issued. Subject to the referral waiver requirements below, if a prior referral is not obtained, eligible expenses incurred for medical care or treatment rendered outside of the Health Services Center or Psychological Services are excluded from coverage. A referral issued by the Health Services Center or Psychological Services must accompany the claim when submitted

 

The referral requirement is waived under the following circumstances: 

  1. For Emergency Medical Condition. The covered student must return to Student Health Services for necessary follow-up care. (Please not that there is a Copay of $50 per visit  to the emergency room, waived only if admitted to the Hospital.)
  2. When Student Health Services is closed.
  3. When service is rendered at another facility during school breaks or vacation periods.
  4. For medical care received when the Covered Student is more than 50 miles from campus.
  5. For maternity care.
  6. For annual routine gynecological/obstetrical services.

 

Benefits for Emergency Medical Condition will be payable at the PPO level whether treatment is received from a PPO provider or Non-PPO provider. Per Patient Protection and Affordable Care Act, if designation of a primary care physician is required, the Covered Person must be allowed to designate a physician who specializes in pediatrics as the child's primary care physician if the provider is in the network. No authorization or referral requirement shall apply to obstetrical or gynecological care provided by in-network providers.

The Covered Student must visit Student Health Services for outpatient care before seeking medical are off-campus.  The Deductible Amount for covered services outside Student Health Services will be reduced to $25 when: 1) a referral is made by a Student Health Service Doctor; or 2) Student Health Services is closed. The applicable Deductible, coinsurance and Copy Amount shall apply to all of the exceptions to the referral requirement shown above. The Deductible Amount does not apply to the Eligible Expenses incurred at the Student Health Services.

To make an appointment at Student Health Services, call: 1-310-434-4262

Hours: Monday-Thursday, 8:00 a.m. to 5:00 p.m.

Friday, 8:00 a.m. to 2:30 p.m., except the first Friday of every month, 8:30 a.m. to 2:30 p.m. (subject to change)

 

Right of Subrogation

The Company shall be fully and completely subrogated to your rights against parties who may be liable to provide indemnity or make contribution in respect of any matter which is the subject of a claim under this insurance.
You further agree to cooperate fully with us in seeking such indemnity or contribution including, where appropriate, insurers instituting proceedings at their own expense against such parties in your name.

Policy coverage, benefits and limitations are summarized in this description of the insurance policy. A policy detailing the benefits of the program is available on request at the International Education Center or the Health Center.

Claims Conditions

This insurance is subject to certain terms, conditions and exceptions. It is important that you read and understand the whole policy wording. Set out below are very important notices, conditions and exceptions.

Claim Procedure


In the event of Injury of Sickness:
  1. Report to Student Health Services for treatment or referral (see Referral Requirement).
  2. After you receive treatment, complete the insurance company claim form.

a.    Download a claim form from www.4studenthealth.com/smc and fill it out completely.

b.    Include your policy number (as shown on your ID card) on the claim form.

c.     Sign the claim for before submitting it.

d.  Attach the SHS referral form.

3.    If you have any other expenses such as medicines, x-rays or laboratory charges, be sure to attach these bills to the claim form.

4.    Send your claim form, referral form (if applicable), and all other bills to Personal Insurance Administrators, Inc., at the address below. Try to have all itemized bills attached to the same claim form.

a.    Please do not send bills without completed claim form and referral form. Bills cannot be considered unless all the information required on the claim form is submitted.

b.    A properly completed claim form must be submitted for each Injury or Sickness.

5.    Claim forms and bills should be sent to:

Person​al Insurance Administrators, Inc.

P.O. Box 6​040

Agoura Hills, CA​ 91376-6040

Provide​rs may submit claims electronically:

PAYER ID 95​​397

6.    If you have questions about the status of your claim after it has been submitted, please call Personal Insurance Administrators, Inc. at 1-800-468-4343.


All Hospital and medical bills must be submitted for payment within 90 days after the first date of treatment. Failure to furnish this information within the 90-day period shall not invalidate nor reduce the Covered Person's claim if it was not reasonably possible to file the claim within this time, provided that the claim is submitted as soon as is reasonably possible. In no event, except in the absence of legal capacity, will a claim be honored later than one (1) year from the date of last medical treatment. Covered Persons have the right to file a written complaint and obtain an expedited review if health care services have been improperly denied, modified, or delayed.
Always keep a copy of all documents submitted for claims.

 

 

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