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How to file an Insurance Claim

The accident medical policy provided by your state soccer association is an excess / secondary policy. If you have other valid and collectable primary insurance, all charges must first be submitted to your primary insurance carrier.

The OYSAN plan is written on an "excess" basis. This means that you must first submit all of your medical bills to your other insurance carrier or health care plan for processing. You will receive and Explanation of Benefits worksheet (EOB) from your other carrier explaining what has or has not been covered by that plan. DO NOT wait until your other carrier has processed all your bills before filing the OYSAN medical claim form. The deductible under the OYSAN plan is $500.

Accidents occurring on or after September 1, 2012:
Use the online claims submission program

Accidents occurring on or before August 31, 2012:
Use the paper claim form found here.

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ONLINE CLAIMS INSTRUCTIONS:

1. Forms MUST be subitted within 30 days of the date of the accident in order for your claim to be eligible for coverage.

2. Start Your Claim: The online claims submission program is for accident dates on or after September 1, 2011. Be sure to choose Ohio Youth Soccer Assocaition North's form online.  (REMINDER: If your accident date was before this date, DO NOT PROCEED WITH THE ONLINE SUBMISSION OF THE CLAIM; instead, you must use the paper claim form.)

• The claimant (injured person) or parent / legal guardian (if claimant is under the age of 18) should complete the online claim form online. A confirmation email will be sent to you upon completion.
• Complete all portions of the OYSAN accident claim form. Failure to complete all sections may result in unnecessary delay in the processing of your claim.
• Additional bills and EOBs can be submitted at a later date (after the initial submission of your claim) to Chartis. Your claim form will have their contact information on it.

3.  The claims information will be sent to your state soccer association for approval or denial. Once approved, you will receive an email with the claim form as a PDF attachment. You will need to send the claim form to the claims payor, Chartis, with the itemized medical provider bills and explanation of benefits (EOB) from your primary carrier (if applicable). If your claim was denied by the state soccer association, you will receive an email indicating the reason for the denial.

4. Sign-off: Have the coach or another local official that witnessed the accident sign off on the claim.  

5. Send/Attach the following documents:

• Copies of fully itemized medical bills. (Itemized bills must show the patient’s name, date of service, the type of service rendered, the diagnosis or nature of condition being treated and the provider’s name and address.)
• Copies of the Explanation of Benefits (EOB) from your primary insurance carrier.