Mutual of Omaha uses this 12-page claim for group critical illness and specified disease benefits. The employee selects the illness or procedure from a long list and attaches test results or records. The attending physician completes Section 4: diagnosis with ICD code, diagnosis and first consultation dates, surgery with CPT codes, hospital stays, and primary care and other treating physicians.
The employee completes Section 1 and the authorizations, and the employer completes Section 3. The attending physician completes and signs Section 4; Section 2, physician, hospital and medication history, is required for claims within the first year of coverage.
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Group Critical Illness/Specified Disease Claim Form
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Section 4, the Attending Physician Statement, asks for the ICD code, diagnosis date, first consultation date, surgery with CPT-4 codes, prior similar illness, whether the patient is still under care, hospital admissions, primary care and other treating physicians, and the physician's specialty, degree, board certifications and tax ID.
Yes. Mutual of Omaha posts a Spanish version of form 454127 alongside the English form. Both are listed for plan members in its online forms finder, under group critical illness claims.
For invasive cancer or carcinoma in situ, the claim lists the pathology report, a clinical diagnosis only if pathological diagnosis is not possible, and the surgical report, with fields for TNM stage, Rai or Binet stage, Clark level and Breslow thickness.