Accident details are requested from a member to determine how the claim should be processed, who is financially responsible, and whether coverage applies. The information helps:
Determine Liability or Third-Party Responsibility
If the injury resulted from an accident involving someone else (e.g., car accident, slip and fall), the claims specialist needs to know if another party may be responsible.
This helps coordinate subrogation, where the member’s plan may seek reimbursement from the responsible party or their insurer.
Verify Coverage Applicability
Some plans may exclude certain types of injuries or have specific rules for accidents, such as work-related or motor vehicle accidents.
Coordinate Benefits
If another insurance (auto, workers’ compensation, or liability) could pay for the treatment first, the health plan needs accident details to avoid paying more than necessary. This is called coordination of benefits.
When a claim is received with a diagnosis code indicating an accident or injury may have occurred, an Accident Investigation Form is assigned to the member via the member portal. The member will receive an email notifying them that the form needs to be completed.
Once completed, the form can be accessed on the Member Information Page under the Forms tab.
Clicking in the completed assigned forms will open the form up to provide the details.
The ability to download the form to a pdf is in the top right corner.
