Pertzborn Agency

Globe Life Family Heritage is dedicated to making your claim filing as easy as possible. This checklist is designed to guide you with filing your claim. Our claims professionals are also available to assist you through the claims process. If you need assistance, please contact us.

Before you start, you will need:

• Policy Number

• Policyholder's Name and Address

• Policyholder's Date of Birth

• Policyholder's Phone Number

 

To file a claim, you will need:

• Patient/Claimant's Name

• Patient/Claimant's Date of Birth

• Patient/Claimant's Relationship to the Policyholder

• Supporting Documents

 

Please obtain the following supporting documents if applicable to your claim:

First Occurence Claim

File when first diagnosed with internal cancer.

• First Occurence Cancer Claim Form (download and print if mailing or faxing your claim)

• Physician's Statement completed by the physician (download and print to submit an eClaim)

• Pathology Report with the positive cancer diagnosis Pathology Report example

• Medical records for a clinical diagnosis of cancer (examples include results of a CT scan, MRI, or ultrasound, and consultation reports of the cancer diagnosis and treatment)

• Biopsy/surgery bill from the surgeon's office (this should include the five-digit CPT medical billing code)

 

Cancer Claim

File after the First Occurrence claim and for skin cancer.

• Cancer Claim Form (download and print if mailing or faxing your claim)

• Physician's Statement (download and print to submit an eClaim)

• Complete, itemized hospital bill Itemized hospital bill example
  UB-04 bill example

• Surgery bill from the surgeon's office (this should include the five-digit CPT medical billing code)

• Pathology Report for each surgery Pathology Report example

• Itemized chemotherapy/radiation billsThis should include the patient's name, drug name, charges/cost and the dates of each treatment or the dates the prescriptions were filled.

• Pharmacy and prescription bills/receiptsThis should include the patient's name, drug name, charges/cost and the dates of each treatment or the dates the prescriptions were filled.

• Any other itemized medical bills, medical records, or supporting documents 1500 HCFA statement example

Transportation and Lodging Claim

• Travel log form (download and print)

• Medical records for the consultation visit

• Itemized medical bills for the consultation visit and/or treatments

• Lodging statement or invoice that includes the room charges for each day (for inpatient hospitalizations only)

• Flight/itinerary invoices