1. You have been provided with a claim form that is designed specifically for USASA. Please use only this form. Do not delay submitting this form as a claim form must be received by A-G Administrators, with or without medical bills, within 12 months from the date of the accident or your claim may be denied for untimely filing.

 

2. Treatment must be initiated and covered expenses incurred within 90 days from the date of the accident. Evidence of this, medical bills or medical records, must accompany the claim to satisfy this provision of the policy.

 

3. Part A must be fully completed and signed by the participant or his/her legal guardian. The claim form must be approved and verified by the League and State Association Verification Officers and then sent to the National Office.

 

4. Submit itemized insurance billing forms. *These forms are available from your health care provider and include the patient’s name, condition (diagnosis), type of treatment and date the expenses(s) was/were incurred. “Balance due” statements are not acceptable.

 

5. If you are covered under other insurance (i.e. employers group plan), give the medical providers involved in your care the other insurance (i.e. employers group plan) as your primary payer and the (USASA) insurance information as the secondary payer. If this is done, the medical provider will automatically bill A-G with the proper itemized bills and provide your Explanation of Benefits (EOB) form. If you were unable to give the medical providers this information before you are balanced billed, A-G will need copies of all itemized bills that show dates of service, diagnosis codes, procedure codes and your primary payer Explanation of Benefits (EOB) forms. If medical providers have the information from both insurance plans your claim will be processed in a more efficient manner.

 

6. Send all paperwork with claim form to gary@upslsoccer.com  to be signed off and sent to USASA. From there it will go to the provider and from that point on it is between the injured player and the insurance company. 

 

SPANISH :