Insurance - Adult
Claim Form- English | Claim Form- Spanish
Georgia Soccer- Adult Medical Insurance Claim Procedures
This memo should be used to advise all league members (coaches, officials, players, parents) of the procedure that needs to be followed to ensure that all medical insurance claims are processed properly.
Georgia Soccer-Adult maintains medical injury insurance for the registered members that have chosen to accept this added benefit. Claims are sent to US Adult Soccer Association and then processed through the insurance company. If the steps listed below are met, medical insurance claims can be processed timely and accurately.
We offer secondary insurance coverage with K&K Insurance. You should file with your primary insurance company first. You will file a claim, with our insurance company, for any remaining balances and/or out of pocket costs incurred.
The deductible per claim is $400.00. This is in addition to any deductible that the primary insurance company already has. The deductible can be paid or it can be met through out of pocket expenses and/or any additional charges that have been incurred.
The claim should be filed within 90 days from the date of injury. If it seems that the medical treatment is going to continue over a significant period of time, we do not recommend that you wait until all services are complete to file. The claim with our insurance company can be filed immediately and verified by our office. It is much easier to add additional charges to an already active claim than it is to initially get the claim started.
Procedures for filing medical insurance claims:
- Injured player completes the USASA Special Risk Accident Claim Form: English | Spanish
- You will find plan limitation and exclusions, rates of pay and filing instructions contained in this form.
- Once the accident claim form is received, Georgia Soccer will verify and forward to US Adult.
- US Adult will complete additional verification and forward the form to K&K Insurance.
- The injured person will then receive a claims acknowledgment letter directly from K&K Insurance. This letter will verify that the claim form has been received and also provide a claim number, which can be given to providers and hospitals as needed or requested.
Depending on the circumstances, some exceptions are made to the above listed procedures. If you have a particular circumstance or questions about our coverage, or if further assistance is needed, please contact:
Director of Operations
Guidelines for Submitting USASA Special Risk Accident Claim Form
- Claim form should be completed in its entirety and sent to Georgia Soccer within 90 days from the date of injury.
- Part B- Question 8, Line A- Must be signed by coach, team manager, referee or league official. Part B- Question 8, Line B- Will be signed by Georgia Soccer official.
- Please be sure to sign page 3, Authorization
- If you have other insurance, submit your itemized bills to the other carrier first. You will receive a payment Explanation of Benefit worksheet (EOB) from your carrier.
- You may attach itemized bills and your other carrier’s EOBs that are ready at the time of submitting this Claim Form. “Balance due” statements are not acceptable.
- Upon receipt of the claim from US Adult, K&K Insurance will provide an acknowledgment letter advising you of your claim. All future correspondence concerning your claim should be directed to K&K Insurance.
- Claim form may be sent to Jade via fax (770-452-1946), email (email@example.com) or USPS (address below).
- Claims will NOT be processed unless they are submitted through Georgia Soccer.
Who do I contact if I need further assistance?
|State Association Contact:
|2323 Perimeter Park Drive NE
||1712 Magnavox Way
|Atlanta, GA 30341
||PO Box 2338
|ATTN: Jade Beaulieu
||Fort Wayne, IN 46801
Affiliates Providing Medical Insurance 2014-2015:
Information will be available by July 18, 2014.
Results: 3 Record(s) Found.