DO NOT SEND ANY CLAIM FORMS TO OUR OFFICE(S).
BELOW IS THE PROPER INSTRUCTIONS FOR SUBMITTING A MEDICAL CLAIM
Instructions for Filing a Medical Claim
A partially completed claim form was provided to the individual that obtained the insurance for your Organization/Event.
This partially completed claim form contains pertinent information that significantly reduces processing time, please use this form to submit all claims, failure to do so will result in processing delays.
- Part 1: Must be filled out completely.
- Part 2: Must be completed if the claimant is a minor and must be fully filled out.
- Part 3: Must be filled out if there is Primary Insurance
- If there is no Primary Insurance, “NO” MUST BE CHECKED OFF AND SIGNED TO AVOID ANY DELAY IN PAYMENT.
- Claimant/injured participant must visit a provider within 30 days from the date of the event/incident. Failure to do so will result in claim denial.
- If you have already paid the bills, please include a receipt or proof of payment.
- A deductible will apply to each claim.
- A League Representative, Promoter or Insurance Coordinator must sign the claim form.
To consider benefits HSRI needs HCFA/UB billing forms (diagnosis codes, procedure codes and the provider’s tax id number). Failure to do so will result in processing delays.
Scanning as PDF and emailing the claim form and all applicable documents to firstname.lastname@example.org is the best submission method.
- Upon receipt of the claim via email, you will receive an acknowledgement email from HSRI.
- Processing of claim will begin immediately.
Alternative Submission Options
- Fax all documents to HSRI at (972) 512-5820
- Send all documents via mail to HSRI (contact information below)
HSRI – Health Special Risk, Inc.
HSR Plaza II
4100 Medical Parkway
Carrollton, TX 75007
Toll Free: (866) 345-0974
Fax: (972) 512-5820
The alternative methods listed above will require additional processing time to gather and enter all provided information into HSRI’s system. For this reason, we highly recommend sending all submissions via email to email@example.com if possible.
Claim Status Inquires
The best form of contact for a claim status update is via phone: (866) 345-0974
Alternatively, you may reach out via email, if so, please provide as much information as possible.