Claims Information

United Schools Associates (USA) and the Assurity claims contact center are available to handle telephone calls from policyholders. The claims contact center can verify coverage to providers, and can answer many questions about policy benefits

There are no claim forms involved in filing wellness benefits – 
However, before calling to file a wellness claim, please compile the following information as it pertains to your wellness exam: the date of service, procedures and/or tests performed, amount charged and the name and contact information for your medical provider. Once you have on hand all the information to file your claim, please call our claims department directly: toll free 1-844-USA-4YOU ext. 2 (1-844-872-4968 ext. 2)

  • Our Wellness Benefit Rider  pays a benefit when a charge is incurred for a specific test or procedure for each of two groups:

$50 per calendar year for each insured category (once for employee and spouse individually, once for children collectively) when a charge is incurred for one of the following after the 30-day waiting period (may vary by state):

  • Annual Physical
  • Blood test and triglycerides
  • CA 19-9 (blood test for pancreatic cancer)
  • Fast blood glucose test
  • Hemoccult stool analysis
  • PSA (blood test for prostate cancer)
  • Pap smear
  • Vision/hearing exams
  • Vaccinations (flu shot, pneumonia shot, tetanus shot, MMR, polio vaccine, chicken pox, diphtheria)
 

$100 per calendar year for each insured category (once for employee and spouse individually, once for children collectively) when a charge is incurred for one of the following after the 30-day waiting period (may vary by state):

  • Biopsy for skin cancer
  • Bone marrow biopsy and aspiration
  • Breast ultrasound
  • CA 15-3 (blood test for breast cancer)
  • CA 125 (blood test for ovarian cancer)
  • CEA (blood test for colon and cervical cancer)
  • Chest x-ray
  • Colonoscopy
  • Flexible sigmoidoscopy
  • Mammography
  • Serum cholesterol test to determine level of HDL and LDL
  • Serum protein electrophoresis (blood test for myeloma)
  • Stress test (bicycle or treadmill)
  • Thermography

Wellness Claims:
Benefit available after 30 days from issued date. Simple have a test or procedure from one or both category groups- Call the USA & Assurity Claim Centertoll free 1-844-USA-4YOU ext. 2 (1-844-872-4968 ext. 2) to process your benefits. Have the following information on hand; The date of service, procedures and/or tests performed, amount charged and the name and contact information for your medical provider.

The following forms are needed to consider a new claim:
Disability Income Claims:

Claim Statement Form # 01-012-02255
Employer’s Statement Form # 01-013-02255
Attending Physician’s Statement Form # 01-014-02255
Confidential Information Authorization Form # 75-500-05055

Emergency Accident Rider under the Disability Income Policy:
Copy of the accident report and an itemized billing showing insured’s name, date of service, diagnosis code, procedure code, and billed amount.

Accident Expense Claims:
Copy of accident report Accident Claim Form # 75-010-02283 Itemized billing showing insured’s name, date of service, diagnosis code, procedure code, and billed amount.

Life Insurance Claims:
Please call Assurity at the number listed above to request the forms.

Critical Illness Claims:
Please call Assurity at the number listed above to request the form.

Hospital Indemnity Claims:
Itemized billing showing insured’s name, date of service, diagnosis code, procedure code, and billed amount.

Cancer Claim:
Itemized billing showing insured’s name, date of service, diagnosis code, procedure code, copy of pathology report and billed amount.

To begin the claim process or request the proper forms, contact the claims contact center using the following:

  • Emailed to: claimsinfo@assurity.com
  • Faxed to: 1-402-437-4592 or toll free fax 1-800-869-0368
  • Mailed to:
    United Schools Associates, Inc. & Assurity Claims Department
    PO Box 82533 Lincoln, NE 68501-2533

    If the claim form is emailed or faxed as described above, please do not mail the original claim form.