Submit a Claim

How to File a Claim

In order to process a medical claim under an accident insurance program, BMI Benefits will need the following documents

  • Fully Completed and Signed Accident Claim Form
  • Itemized Medical and Dental Bills
  • Primary Insurance Explanation of Benefits (EOB) where applicable

These documents can be mailed, faxed, emailed directly to BMI, or uploaded through BMI’s secure FTP link. Accident claim forms should be submitted within 90 days from the date of accident and bills should be submitted within 1 year from the date of service to avoid any denial due to timely filing.

BMI Benefits, LLC.
Attn: Claims
P.O. Box 511
Matawan, NJ 07747
Phone: 800.445.3126
Fax: 732.583.9610

Learn More About the Documents

Accident Claim Form
Accident Claim Form
The accident claim form (injury report) is the document that allows BMI to open a claim. You should have received the partially completed and signed accident claim form from the appropriate school or organization official. This person might have been an athletic trainer, athletic director, nurse or a person from the Business Office. Please complete the remainder of the form in its entirety and submit to BMI Benefits within 90 days from the date of accident. Please retain a copy for your records. If you do not have the accident claim form, please request from the school or organization. If the school or organization has already submitted the accident claim form directly to BMI, please contact BMI to confirm that the form is on file.
Itemized Medical and Dental Bills
Itemized Medical and Dental Bills
In order for BMI to process any outstanding medical or dental bills, or process reimbursements for medical bills paid out of pocket, you will need to submit the itemized bills. Balance due statements or balance forward statements from the medical provider will NOT suffice as they do not include all of the needed billing information required by the insurance. Proper itemized billing forms include the providers complete Name and Billing Address, Tax ID Number, Dates of Service, Types of Services Rendered, Proper CPT and ICD-10 Codes, and Fees Charged by Service Rendered. The proper billing forms required by insurance are listed below for each type of medical provider.
o Physician’s Billing – HICFA 1500 Form (hyperlink to sample form)
o Hospital/Facility Billing – UB04 Form (hyperlink to sample form)
o Dental Billing – ADA Dental Claim Form (hyperlink to sample form)
Please contact the medical providers and request the above documents. You can also ask the medical provider to bill BMI directly. To do this, you will need to tell them you have secondary insurance through BMI Benefits and provide our billing information.
Primary Insurance Explanation of Benefits (EOB)
Primary Insurance Explanation of Benefits (EOB)
The accident insurance is excess of all other valid and collectible insurance. If you have other insurance, all medical bills must be submitted to that insurance carrier and processed first. Any remaining charges left as patient responsibility, are eligible to be submitted to BMI for processing. Please send the complete other insurance EOB.

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    The Hartford Fire Insurance Company and The Hartford Life and Accident Insurance Company

    The Hartford Fire Insurance Company and The Hartford Life and Accident Insurance Company

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