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:

Heart or Stroke Claim

• Heart 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)

• Medical records with the heart disease, heart attack, or stroke diagnosis Examples include a catheterization report, medical test results, hospital admission and discharge summaries, or MRI and CT scan reports. These can be obtained from the diagnosing/treating physician or the facility's medical records department.

• Complete, itemized hospital bill listing the daily room charges Itemized hospital bill example
  UB-04 bill example

• Ambulance bill

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

• Itemized physical therapy bills

• Any other itemized medical bills, medical records, or supporting documents1500 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