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It captures claim totals, company retention, eligible amounts, and additional circumstances such as COB, accident details, and subrogation/right to recovery. 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Box 535061  \nPittsburgh, PA 15253-5061  \nOr email to: [HMSpecialtyClaims@hmig.com](HMSpecialtyClaims@hmig.com)  \nPhone: 800-328-5433  \nHM SPECIALTY CLAIM FORM  \nType of Claim:  Initial Request for Reimbursement  Subsequent Request for Reimbursement  \n\n| GENERAL INFORMATION |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Reinsurance Agreement \\#: |  |  | Agreement Year:\u003Cbr>through |  |\n| Company: | Covered Person: |  |  |  |\n| Claimant: |  |  | D.O. B.:\u003Cbr> / /  | Sex:  Male  Female |\n| Covered Person (Insured): | Relationship: |  |  |  |\n| Plan Type:  PPO  Medicaid  Medicare POS  HMO CHIP\u003Cbr> Medical Excess  Accident Other:  |  |  | Claimant Effective Date: |  |\n| Diagnosis(es) : | ICD Code (Listed on Page 3): |  |  |  |\n\n\n| CLAIM INFORMATION |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Health Care Provider | Contracted Facility | Billed Charges |  | Amount Paid | Eligible Amount |\n|  |  Yes  No | $ |  | $ | $ |\n|  |  Yes  No | $ |  | $ | $ |\n|  |  Yes  No | $ |  | $ | $ |\n|  |  Yes  No | $ |  | $ | $ |\n| Total Claim:$ |  |  | Company Retention:\u003Cbr>$ |  |  |\n| Total Reimbursement Being Requested:\u003Cbr>$ |  |  |  |  |  |\n\n\n| ADDITIONAL INFORMATION |  |  |\n| --- | --- | --- |\n| COB: | If Yes, Please Indicate the Name of the Other Carrier: |  |\n| Accident: | If Yes, Please Indicate How, Where and When the Accident Occurred: |  |\n| Subrogation/Right to Recovery:\u003Cbr>If Yes, Please provide a Copy of the Signed Subrogation Letter. |  | Comments: |\n\n\n| SUBMISSION INFORMATION |  |\n| --- | --- |\n| Submitted By: | Today’s Date:\u003Cbr> / /  |\n| Title: | Tel \\#: |\n| Address: |  |\n\nThe following items are required before reimbursement request can be processed:  \nEligibility-Copy of the original enrollment application with initial claim submission UB-92 Hospital Bill Summary Copy of Physician, drug and DME bills (if applicable) Proof of Claim Payment (explanation of benefits or worksheet)  \nFRAUD NOTICE  \nAny person who knowingly and with intent to defraud or deceive any insurance company submits an insurance application or statement of claim containing any false, incomplete or misleading information may be subject to civil or criminal penalties, depending upon state law.  \nIn Alabama, any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.  \nIn Arkansas, any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information inan application for insurance is guilty of a crime and may be subject to fines and confinement in prison.  \nFor your protection, California requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.  \nIn the District of Columbia, WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.  \nIn Florida, any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.  \nIn Kentucky, any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Any application for insurance in writing by the","cbCaifFHudVV7SwC","https://ap.wps.com/l/cbCaifFHudVV7SwC","pdf",165036,"English","# General Information\n# Claim Information\n## Provider Charges and Payment Details\n# Additional Information\n# Submission Information\n# Required Items for Reimbursement Processing\n# Fraud Notice","[{\"question\":\"What types of claims can be submitted on the HM Specialty Claim Form?\",\"answer\":\"The form supports an Initial Request for Reimbursement and a Subsequent Request for Reimbursement.\"},{\"question\":\"Which general information fields are requested in the form?\",\"answer\":\"It collects reinsurance agreement details, company and covered person information, claimant information including relationship and DOB, plan type, diagnosis(es), and agreement year/date range.\"},{\"question\":\"What additional items are required before reimbursement can be processed?\",\"answer\":\"Eligibility proof is required, including a copy of the original enrollment application, UB-92 hospital bill summary, copies of physician/drug/DME bills if applicable, and proof of claim payment such as explanation of benefits or a worksheet.\"}]","HM Specialty Claim Form - Initial and Subsequent Reimbursement Request | PDF"]