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.
Claims pending an accident form
When a claim triggers an Accident Investigation Form, the claim is pended (held for manual review) and is not paid or denied automatically until the form is returned.
If the form is not completed, the member receives a reminder email once a week, up to 4 reminders. After the last reminder, the claim is flagged to the Yuzu team for manual follow-up
A completed form is valid for 60 days. Accident-related claims received in that window use the same form, and the member is not asked to fill it out again
For professional claims, the claim is held only when the provider marked it as related to an auto accident or employment
Reprocessing after the form is returned
Once the member submits the form, Yuzu re-checks pended claims automatically each business day. If the member reports no accident, or that no third party was involved and no liability claim was filed, the claim continues processing normally. If the form shows a third party or a liability claim, the claim stays in manual review so the claims team can coordinate benefits or subrogation. Claims that were already denied for a missing accident form are not reprocessed automatically. The claims team reviews these after the form comes in and reprocesses them. To request reprocessing for a specific claim, send the claim number to claims@yuzu.health.
What an accident investigation denial means
A claim denied with remark code INJURY was denied because Yuzu needed accident details to determine who is responsible for payment, and did not receive them. It does not mean the service is not covered. To resolve it, the member completes the Accident Investigation Form in the member portal. Once the form is on file, the claim can be reprocessed.
Other coverage: auto, workers' compensation, and third-party liability
As noted in Coordinate Benefits above, other coverage may need to pay first. Send the following to claims@yuzu.health with the claim number:
Auto coverage exhausted: the auto insurer's exhaustion letter or final EOB showing PIP/MedPay benefits are used up, with the auto carrier name and claim number
Workers' compensation: the workers' comp carrier's denial or determination letter, or confirmation that the injury was not work-related
Third-party liability: the responsible party's insurer, claim number, and attorney contact details (if any). The member may be asked to sign a subrogation agreement