The following will assist parents/guardians with submitting a Student Accident claim. The claim should be submitted within 90 days of the date of the accident, even if all the needed documentation is not yet available. If the claim form is not submitted within 90 days of the date of the accident, the claim could be denied for late filing. To expedite claim processing, it is important that all required information is provided – see details below. Student Accident Insurance is a secondary insurance plan which is available to you when your child is injured in a school supervised and sponsored activity. This is intended to be Excess coverage, secondary to a student’s normal health insurance. All medical expenses for accidental injuries should be submitted to your health plan first. If you do not have health insurance, the Student Accident plan will provide benefits for covered accidents according to the policy’s schedule of covered expenses. Please include the school name and student accident policy number on any documentation submitted for the claim.

1. Claim Form – This form can be obtained from the school. The school can print out the form for the parents/guardians. The school can also email the form to the parent/guardian, as most of the information can be typed into the Claim form, which is a fillable PDF.

• STUDENT INFORMATION (Parts 1-9) – All information related to the student must be included. Social Security Number optional. Cell phone number should be for the parent/guardian that can be easily contacted if there are any questions.

• ACCIDENT INFORMATION (Parts 10-20) – All information related to the accident including activity, date of accident, body part injured, where the accident occurred and details of the accident.

•  AUTHORIZATION – This section must be signed by the parent/guardian and a school official such as a coach, athletic trainer or nurse. The school official might want to sign off after including the information about the accident and then give to the parent/guardian to submit to HSR.

• INSURANCE INFORMATION - Parent/guardian needs to complete this section including their primary health insurance information with policy and ID number. If the parents/guardians do not have medical/dental insurance, this must be noted on the form. To avoid delays in claim processing, insurance section of the claim form must be completed in full.

1. Itemized Bills (include school name and policy number) – This can be obtained from the treating physician’s or dentist’s office. It will include the name and address of the provider of service, date of service, type of service and the related charges. Even though account statements or “balance due” statements are helpful, they do not contain all the information needed to process the charges. To avoid delays in claim processing, an Itemized Bill should be provided.
2. Explanation of Benefits (EOB) (include school name and policy number) - If the student has health insurance, all medical bills must first be submitted to their primary health insurance carrier. A copy of the “Explanation of Benefits” form provided by the primary carrier, must be submitted with the claim. If the student does not have primary medical insurance, the need for an “Explanation of Benefits” will not be applicable to the claim, and only the Claim Form, along with the Itemized Bills, should be submitted.
3. Once all information is completed on the Claim form, and all the necessary documents have been gathered, the claim can be submitted via mail, email or fax to the third-party administrator, Health Special Risk, Inc., by the parents/guardians.

    

• Mail
• Health Special Risk, Inc.
• Claims Department
• P.O. Box 117558
• Carrollton, TX 75011-7558

• Email - K12claims@hsri.com
• Include school name, policy number and student name in the Subject.

• Fax - (972)- 512-5818
• Include school name, policy number and student name on the cover page of the Fax.

1. Claims Status - To find out the status of a claim, parents/guardians can contact HSR, Inc. as follows:
   
   Phone: (866) 409-5734
   
   The parent/guardian can also visit HSR’s website and complete a form electronically. A member of HSR’s team will then be in touch with the parent/guardian.