Disability and Life

Online Claims

Submission

User Manual for Employees

Life and Disability products underwritten by UniCare Life & Health Insurance Company. ® Registered mark of WellPoint, Inc.

7/13

2

Table of Contents

Introduction ................................................................................................................................................... 3

Getting Started .............................................................................................................................................. 4

Submitting an Accidental Dismemberment claim ........................................................................................ 5

Submitting a Living Benefit claim .............................................................................................................. 12

Submitting a Life Waiver of Premium claim .............................................................................................. 19

Submitting a Short Term Disability claim .................................................................................................. 28

Submitting a Long Term Disability claim .................................................................................................. 37

3

Introduction

Our online claim submission site provides a convenient way for you to submit disability claims (short term and long

term disability) and life waiver of premium, accidental dismemberment and Living Benefits claims. It saves you

time by not having to mail or fax your claim to us and can speed up the process because your claim gets sent directly

to our system.

This manual offers step-by-step instructions on how to submit your claims online. If you have questions, you can

call us at:

For life claims: 800-552-2137

For disability claims: 800-813-5682

4

Getting Started

You’ll select the type of claim you want to submit on the Welcome screen. The options are:

Accidental Dismemberment

Living Benefit

Life Waiver of Premium

Short Term Disability

Long Term Disability

Fields marked with an asterisk* are required.

5

Submitting an Accidental Dismemberment claim

To submit a claim for an accidental dismemberment, select “Accidental Dismemberment” in the Type of Claim

field. In the Type of User field, select “Employee.”

Enter the characters you see in the bottom box, then click “Next.”

6

A pop up message will appear showing the additional forms you will need to complete your claim.

You can click on the links to download and print fillable PDF versions of the forms:

Employer’s Statement

Attending Physician Statement

7

Please give us as much information as possible on the Employee/Employer Information screen.

8

On the Accident Information screen, give us as much information as you can about the accident that

caused the loss.

9

If you have completed at the time you enter the claim, you can scan them and upload them on this

screen. For example, if you have Employee’s Statement and/or Attending Physician Statement you

can scan and attach them here.

10

Next you’ll get confirmation of the information you entered and you’ll give your certification to us

that we can begin processing the claim. You can also enter your email address and we’ll send you

confirmation of all the information you entered.

11

Once the claim is complete, you’ll receive a confirmation summary showing all the information you

entered. If you entered your email on the prior screen you’ll also get a confirmation summary by

email.

12

Submitting a Living Benefit claim

To submit a claim for a Living Benefit (Accelerated Death Benefit), select “Living Benefit” in the Type of

Claim field. In the Type of User field, select “Employee.”

Enter the characters you see in the bottom box, then click “Next.”

13

You can print the forms we need to process the Living Benefit claim from this screen. Click on the

links to get fillable PDF files of the forms:

Employer’s Statement

Attending Physician Statement

Disclosure Statement

14

On the Employee Information screen, you’ll give us the information we need to begin processing of

the Living Benefit claim. Be sure to give us as much information about the medical condition as you

can.

15

You’ll enter your Employer’s contact information on the Employer Information screen.

16

If you have forms completed at the time you enter the claim, you can scan them and upload them on

this screen. For example, if you have Employee’s Statement, Attending Physician Statement, and/or

Disclosure Statement you can scan and attach them here.

17

Next you’ll get confirmation of the information you entered and you’ll give your certification to us

that we can begin processing the claim. You can also enter your email address and we’ll send you

confirmation of all the information you entered.

18

Once the claim is complete, you’ll receive a confirmation summary showing all the information you

entered. If you entered your email on the prior screen you’ll also get a confirmation summary by

email.

19

Submitting a Life Waiver of Premium claim

To submit a claim for a Waiver of Premium for life insurance, select “Life Waiver of Premium” in the Type of

Claim field. In the Type of User field, select “Employee.”

Enter the characters you see in the bottom box, then click “Next.”

20

You can print the forms we need to process the Life Waiver of Premium claim from this screen. Click

on the links get fillable PDF files of the forms:

Life Waiver of Premium Employer’s Statement

Life Waiver of Premium Attending Physician Statement

21

On the Employee/Employer Information screen, you’ll give us the information we need to begin

processing your Life Waiver of Premium claim. Be sure to give us as much information about the

medical condition as you can.

22

Next, you’ll give us information about your disabling condition. Be sure to provide as much detailed

information as you can.

23

Continued

24

If you have forms completed at the time you enter the claim, you can scan them and upload them on this

screen. For example, if you have the Life Waiver of Premium Employer’s Statement or Life Waiver of

Premium Attending Physician Statement, you can scan and attach them here.

25

Next you’ll get confirmation of the information you entered and you’ll give your certification to us

that we can begin processing the claim. You can also enter your email address and we’ll send you

confirmation of all the information you entered.

26

Continued

27

Once the claim is complete, you’ll receive a confirmation summary showing all the information you

entered. If you entered your email on the prior screen you’ll also get a confirmation summary by

email.

28

Submitting a Short Term Disability claim

To submit a claim for Short Term Disability, select “Short Term Disability” in the Type of Claim field. In the

Type of User field, select “Employee.”

Enter the characters you see in the bottom box, then click “Next.”

29

You can print the forms we need to process the Short Term Disability claim from this screen. Click

on the links get fillable PDF files of the forms:

Attending Physician Statement

Individual Authorization Form

Reimbursement Agreement

30

Enter your contact information and all the information you have about your disabling condition. Be

sure to give us as much detail as you have, to help us process your claim.

31

Next, enter your Employer’s contact information and information about your job.

32

Next, you’ll give us information about your disabling condition. Be sure to provide as much detailed

information as you can.

33

Be sure to provide as much detail as you can to help us in processing your claim.

34

If you have forms completed at the time you enter the claim, you can scan them and upload them on this

screen. For example, if you have the Attending Physician Statement, Individual Authorization Form,

and/or Reimbursement Agreement you can scan and attach them here.

35

Next you’ll get confirmation of the information you entered and you’ll give your certification to us

that we can begin processing the claim. You can also enter your email address and we’ll send you

confirmation of all the information you entered.

36

Once the claim is complete, you’ll receive a confirmation summary showing all the information you

entered. If you entered your email on the prior screen you’ll also get a confirmation summary by

email.

37

Submitting a Long Term Disability claim

To submit a claim for a Long Term Disability, select “Long Term Disability” in the Type of Claim field. In the

Type of User field, select “Employee.”

Enter the characters you see in the bottom box, then click “Next.”

38

You can print the forms we need to process the Long Term Disability claim from this screen. Click on

the links get fillable PDF files of the forms:

Attending Physician Statement

Individual Authorization Form

Reimbursement Agreement

39

You’ll enter your contact information and your Employer’s contact information on this screen.

40

Be sure to give us as much information about your job as you can.

41

Enter informaiton about the disabling condition on this screen. Be sure to provide as much detail as

you can to help us in processing your claim

The questions will change based on the Reason Stopped Work chosen:

Illness

Injury

Maternity

42

No matter the Reason Stopped Work chosen, you will need to give as much informaiton about your

doctor and your other income as possible.

43

Continued

44

If you have forms completed at the time you enter the claim, you can scan them and upload them on this

screen. For example, if you have the Attending Physician Statement, Individual Authorization Form,

and/or Reimbursement Agreement you can scan and attach them here.

45

Next you’ll get confirmation of the information you entered and you’ll give your certification to us

that we can begin processing the claim. You can also enter your email address and we’ll send you

confirmation of all the information you entered.

46

Once the claim is complete, you’ll receive a confirmation summary showing all the information you

entered. If you entered your email on the prior screen you’ll also get a confirmation summary by

email.