File a Hospital GAP PLAN® Insurance Claim
American Fidelity’s Hospital GAP PLAN® Insurance is a supplemental, limited benefit medical expense policy that is designed to help pay the deductible and co-insurance when you or a family member receive inpatient care.
When filing a gap insurance claim you will need to provide the following documentation:
- Statement of Insured, completed via online claim filing or paper claim form
- Itemized Bills with diagnosis from each of your providers with a complete breakdown of charges for each date of service
- Explanation of Benefits (EOB) from your primary medical insurance carrier
We may also need:
- Authorization to Disclose Information Including PHI: This form gives us authorization to get records from your medical provider(s) and others who may hold information necessary for us to review your claim. Upload the form via your online account, or mail or fax it.
TIP: When completing a paper claim form, please submit a separate form for each unique diagnosis.