English - Microsoft Word - US Club Soccer Accident Medical-Dental Insurance Claim Form - Youth

Spanish - US-Club-Soccer-Accident-Medical-Dental-Insurance-Claim-Form-Youth-Spanish.pdf (usclubsoccer.org)

1. Claim eligibility timing: For claims to be eligible for coverage, this form must be submitted no later than 90 days after the date of injury, and medical attention must be received no later than 60 days after the date of injury.
2. Benefit period: This policy is subject to a 52-week benefit period from date of injury. Medical or dental expenses that are incurred within 52 weeks of the date of injury are eligible for coverage under this policy. Any expenses or treatments that are rendered after the 52-week benefit period will not be covered by this policy.
3. Submit a claim form. For claims regarding incidents that occurred through the 2022-23 season (ending July 31, 2023): The claimant, or a parent/guardian if the injured person is a minor, is to complete the applicable section of the US Club Soccer Accident Medical-Dental Insurance Claim Form (Youth) (English / Español) and email it to insurance@usclubsoccer.org. Please do not send bills, Explanations of Benefits (EOBs), or other information to US Club Soccer.
4. Internal US Club Soccer verification. After you submit this form, US Club Soccer will review claim eligibility and verify the accident with the claimant’s club/member organization.
5. Post-verification claim status update. You will receive an email with the claim status when the verification is complete. If approved, the claim will be processed by either A-G Administrators (for accidents occurring through July 31, 2023) or ACI (for accidents occurring on or after Aug 1, 2023).
6. Communication and instructions from the claims processor. You will then receive communication from A-G Administrators or ACI with instructions for you/your providers to submit documentation (bills, EOBs, etc.) directly to the claims processor.
7. After US Club Soccer approval of a youth membership claim for an injury that occurred on or before July 31, 2023, contact A-G Administrators at claims@agadm.com or (610) 933-0800.
8. After US Club Soccer approval of a youth membership claim for an injury that occurred on or after Aug 1, 2023, contact ACI at claims@acitpa.com or (888) 293-9229.