Insurance Billing Policies

INSURANCE BILLING POLICIES

Applicant / Insured Information

Insured Name:    Policy Number:

Policy Details

General Liability    Property    Auto    Life

Policy Period Start:    End:

Covered Services and Billing Codes

The parties agree that covered services and applicable billing codes shall conform to the policy schedule. Included coverages (select all that apply):

Medical Services    Surgical Services    Pharmacy    Therapy / Rehabilitation

Billing Procedures and Payment Terms

Billing Cycle:    Payment Due Within (days):

Grace Period (days):    Late Fee: per month on past due balances.

Accepted Payment Methods:
Electronic Bank Transfer    Credit/Debit Card    Paper Check

By authorizing electronic debit, the insured expressly permits debits for premiums, copayments, deductibles, and adjudicated claim balances. This authorization remains in effect until revoked in writing with at least 30 days' prior notice.

Assignment of Benefits and Provider Payments

Assignment of Benefits: The insured may assign policy benefits to a provider. If an assignment is executed, payments made by the insurer shall be made payable to the provider to the extent of covered services. The insured remains liable for any amounts not covered by the insurer, including charges resulting from non-covered services, prior balances, coinsurance, and deductibles.

Authorize Assignment: I authorize direct payment to providers pursuant to assignments executed under this policy.

Claims Submission and Documentation

Claims must be submitted within days of the service date. Required documentation includes itemized invoices, medical records when applicable, and proof of payment for non-assigned claims.

Refunds, Adjustments and Offsets

Where overpayment is identified, refunds or adjustments will be processed within days. The insurer reserves the right to offset any refund against current or future premiums or outstanding balances under the insured's policy.

Disputes, Appeals and Collections

Billing disputes must be submitted in writing within days of the billed date. The insurer will investigate and respond within 30 days of receipt of complete documentation. Failure to pay undisputed amounts may subject the account to collection procedures, interest, and reporting to consumer reporting agencies where permitted by law.

Exclusions and Limitations

Standard policy exclusions apply, including but not limited to willful misconduct, experimental treatments, losses arising from war, and fraud. Any supplemental or rider exclusions are binding where applicable to the insured's policy schedule.

I acknowledge that I have read and understand the exclusions and limitations described in my policy and in this Billing Policies document:

Coordination of Benefits

Where multiple coverages exist, benefits will be coordinated in accordance with policy provisions. The insured must disclose other coverage and cooperate with subrogation and recovery actions. The insurer may seek reimbursement from other responsible parties for amounts paid under this policy.

I authorize release of necessary information to coordinate benefits and to permit recovery actions:

Privacy, Electronic Communications, and Notices

Communications and billing notices may be sent electronically where permitted. Electronic delivery is deemed effective on transmission. Confidential information will be used and disclosed only as necessary for billing, payment, claims processing, and as permitted or required by law.

I consent to receive billing statements, notices, and communications related to claims and payments electronically at the contact information provided and acknowledge my responsibility to maintain current contact information.

Amendments and Policy Modifications

The insurer may amend billing practices and procedures upon written notice to the insured in accordance with the policy. Continued payment of premiums following such notice constitutes acceptance of amended billing terms.

Beneficiary Information (if applicable)

Declaration and Certification

By signing below, the insured certifies that the information provided in this Billing Policies form is true and correct to the best of their knowledge. The insured acknowledges receipt of these Billing Policies, accepts responsibility for charges not paid by the insurer, and authorizes the insurer and providers to exchange information necessary to process claims, coordinate benefits, and effect payment. The insured further acknowledges that failure to comply with payment terms may result in termination of coverage or referral to collections as permitted under the policy and applicable law.

Agreement Acknowledgement: I have read, understand, and agree to the Insurance Billing Policies set forth in this document.

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