Hospital Confinement/Outpatient Surgery Claim

Tips for Filing a Hospital Confinement/Outpatient Surgery Claim

Below are some helpful tips to guide you through the claims process. If you would like more information make sure to download the Hospital Confinement/Outpatient Surgery Claim Form or view our claims videos.

  • Complete Section 1.
  • If you’re filing for an accident, complete Section 2. The accident date and description are required when filing a hospital confinement/outpatient surgery claim due to an accident.
  • Have your doctor complete Sections 3 and 4 in their entirety, as applicable.
  • Sign and date your claim form, and complete and sign the authorization page prior to filing.

To ensure faster filing, please include the following:

  • A copy of the accident report (if you were in an auto accident)
  • All itemized bills, including medical services (including dates of service), procedure codes, diagnosis codes, anesthesia, etc., which you can get from your doctor