The Standard's group hospital indemnity benefits pay for hospital stays, and the claim packet includes an Attending Physician's Statement confirming the admission and treatment. The physician lists dates of service with diagnosis descriptions, CPT procedure codes and procedure descriptions, then confirms symptom or injury date, first consultation, prior similar conditions, hospital admission and discharge dates, and any surgery done or planned.
The insured or patient completes Section A and passes the form to the physician. The attending physician completes Sections B and C; the employee completes the Employee's Statement and authorization separately.
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Hospital Indemnity Benefits Claim (Attending Physician's Statement)
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For each date of service, Section B asks for a diagnosis description with diagnosis code and a CPT procedure code with procedure description. The physician also gives the date symptoms appeared or the injury happened and the date of first consultation for the condition.
The form states that the patient is responsible for obtaining a complete form without expense to The Standard. The insurer does not pay the physician for completing Sections B and C, so any charge is between the patient and the practice.