Claim Forms

Please click on the appropriate claim forms shown below:

• Paper Claim Forms

• Online Claim Form

• Pharmacy Reimbursement

• Eye Reimbursement

CLAIM FILING INSTRUCTIONS

Injuries and hospitalizations should be reported to the Student Health Center Insurance Office no later than 48 hours from the time of treatment, if treatment is not received at the SHC. Students MUST return to the SHC for all follow-up treatment. Expenses incurred for medical treatment rendered outside of the Student Health Center, for which no prior approval or referral is obtained are excluded from coverage.

It is the responsibility of the student to initiate the insurance procedure. The insurance claim forms may be obtained online through the website listed below.
In the event of an Injury or Sickness:

1. Students must report to the Student Health Center first, where treatment will be administered or, if necessary, a referral to another facility/provider will be provided.

Students do not have to report to the SHC first if: 1) it is an Emergency; or 2) the student is outside a 50-mile radius of the SHC. Treatment received outside of the SHC is not paid at 100%. Students MUST notify the SHC no later than 48 hours from the time of treatment, if treatment is not received at the SHC. Students MUST return to the SHC for all follow-up treatment. Expenses incurred for medical treatment rendered outside of the Student Health Center, for which no prior approval or referral is obtained are excluded from coverage.

2. Students who do not use the SHC due to one of the circumstances listed above may obtain treatment from the nearest Doctor or Hospital. However, using the Doctors and Hospitals available through First Health Network (PPO) may lower the costs of medical expenses. For a complete listing of these PPO Hospital and Doctor facilities, call (800) 226-5116 or visit: www.myfirsthealth.com. If you go to a Doctor’s office or to the Hospital, you must show your insurance identification card (download at www.renstudent.com/idcards).

3. After receiving treatment, complete the insurance company claim form, which may be downloaded from the Student Health Center website at www.shc.uci.edu or from www.renstudent.com/uci. Students who receive a referral from the SHC are still responsible for submitting the completed claim form.

4. Mail itemized medical and Hospital bills along with the Company claim form to:
Personal Insurance Administrators, Inc.
P.O. Box 6040
Agoura Hills, CA 91376-6040

For quicker claims payment, be sure the bills submitted include the following:
• Student’s name and address
• Student ID Number
• Policy Number 302-048-0407
• Name and address of the Doctor or Hospital
• Doctor’s diagnosis
• Itemization of charges, which must include diagnostic and procedure codes (Attach bills!)
• Date Sickness or Injury occurred
• Drug bills (not cash register receipts) showing prescription number, name of drug, date prescribed, and name of person for whom drug is processed.

All of the above items are required in order to accurately pay your claims. Certain claims may require additional information before being processed. All payments will be issued directly to the provider of service unless you submit receipted bills showing payment has been made.

6. For all claims questions, please contact Personal Insurance Administrators, Inc. (PIA) at the address above or call toll-free (800) 468-4343.The Undergraduate Student Health Insurance Plan (USHIP) uses PIA as a third party claims administrator to process all USHIP claims.
The completed claim form and all hospital and medical bills must be submitted for payment within 90 days after the date loss occurs. Failure to furnish this information within the 90-day period shall not invalidate nor reduce your claim if it was not reasonably possible to file the claim within this time, provided that the claim form 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 first medical treatment.
Also keep in mind that if you are covered by another insurance policy, the other policy must pay their portion first and then the explanation of benefits (EOB) must then be provided to PIA to pay their portion (if any).

All claims submitted are subject to review under the terms and conditions of the policy. Verification of eligibility does not guarantee payment of claims. Always keep a copy of all documents submitted for claims.