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Tokio Marine HCC - MIS Group Claims FAQ

Tokio Marine HCC - MIS Group Claims FAQ

Tokio Marine HCC - MIS Group is happy to work directly with any provider, whether local or international. If the provider is willing to submit the bill to us, you the patient will need to submit a completed Claimant's Statement and Authorization form. If the provider requires you to pay up front, you may submit the original, itemized bills and paid receipts to us with the Claimant's Statement.

Tokio Marine HCC - MIS Group receives the documentation for your claim, a file will be set up and the claims will be reviewed within 15-30 business days. If additional information is needed in order to make a benefit determination, the claim representative will begin a written request. Additional information requests may include: medical records, itemized bills, or copy of passport. Once all necessary information has been received and reviewed, an Explanation of Benefits and any payment check will be issued within ten business days.

Do I have to use a doctor from a specific list?

You are always free to use the medical providers of your choice. Benefits in the US differ for some plans when providers within the Tokio Marine HCC - MIS Group PPO Network are used. You may access search pages for network using Tokio Marine HCC - MIS Group PPO Network for both the US and international networks.

Tokio Marine HCC - MIS Group uses these networks as its provider listings. When you make an appointment with the provider, you should verify with the provider's business office that they are indeed contracted with the appropriate network (if a contract has recently been changed, it might not yet be reflected on the website).

Please note, a provider's participation in the network does not guarantee that they will accept payment directly from Tokio Marine HCC - MIS Group, and this provider referral does not guarantee that the services will be covered by the insurance. Please be aware that we are not providing medical advice, but rather information. The ultimate choice to seek medical treatment is yours.

Do I need to pre-certify Tokio Marine HCC - MIS Group for a doctor visit?

Tokio Marine HCC - MIS Group does not require pre-certification for simple doctor visits. Contact Tokio Marine HCC - MIS Group in advance or within 48 hours for the following:

  • Transplants
  • Inpatient Care
  • Surgery or Surgical Procedure
  • Extended Care Facility
  • Home Nursing Care
  • Durable Medical Equipment
  • Artificial Limbs
  • CAT scans & MRIs
  • Maternity

Maternities must be pre-notified within the first 90 days of the pregnancy and again within 48 hours following the delivery. Maternity coverage varies by plan.

The following items must be pre-notified in advance and coordinated by Tokio Marine HCC - MIS Group to be considered for coverage:

  • Trip Interruptions
  • Repatriation of Remains
  • Emergency Medical Evacuation
  • Emergency Reunion

What will happen if I do not pre-certify?

Eligible Medical Expenses will be reduced by 50%, the deductible, if applicable, will be subtracted from the remaining eligible amount, and then the Benefit Percentage will be applied. If Pre-certification requirements are not met for transplant treatment, benefits are forfeited for all services or supplies for the Transplant.

What happens if I become ill or injured over the weekend and need to contact Tokio Marine HCC - MIS Group?

Please call any of the phone numbers listed on your insurance ID card. All collect calls are accepted. World Service Center representatives are available 24 hours a day, 7 days a week for benefit inquiries, pre-certifications, and general assistance.

Once I pre-certify treatment, is coverage guaranteed for that treatment?

Pre-certification is not a guarantee of benefits. Although you've completed the Pre-certification Requirement, all plan provisions and conditions must be met at the time of treatment. Any benefit cannot be authorized or guaranteed any benefit prior to the service.

Do I have to pay the doctor up front?

If a medical provider is willing to bill Tokio Marine HCC - MIS Group directly, then we are happy to work directly with the provider. The provider should submit to us original itemized bills. You the patient will still need to submit to us a completed Claimant's Statement and Authorization. If the provider requires you to pay up front, you may submit the original itemized bills and paid receipts to us along with a completed Claimant's Statement.

Note: For plans that offer a coinsurance waiver for expenses incurred within the PPO, expenses need to be billed by the provider directly to Tokio Marine HCC - MIS Group.

How do I get a Claimant's Statement?

You may obtain a copy of the Claimant's Statement by visiting Client Center section. If you do not have access to the internet, please feel free to contact World Service Center so that we may send a form to you by fax or by mail.

Do I need to send a completed Claimant's Statement and Authorization with every bill?

No, you should submit one Claimant's Statement to Tokio Marine HCC - MIS Group for each different condition or diagnosis only.

Does my plan cover prescription drugs?

Most Tokio Marine HCC - MIS Group policies do not have a prescription drug card. Prescriptions should be paid for at the pharmacy then submitted to us as a claim for reimbursement. Please include the prescription label and your paid receipts with a completed Claimant's Statement.

Can my doctor call if they have questions about what my plan covers?

Yes. We can define the benefits that are available within your coverage; however, we cannot pre-approve any treatment or guarantee payment in advance.

How long will it take for my claim to be processed?

The claims department needs at least 15-30 business days to set up a file and begin reviewing a submitted claim. If additional information is needed to process the claim, written requests will be sent at that time. After all required information is received and reviewed, the claims will be processed according to the terms of the insurance.

How do I find out about status of submitted claims?

You are welcome to contact Tokio Marine HCC - MIS Group during their regular business hours (8:00am to 6:30pm Eastern Time) to inquire about the status of a claim

Is the Explanation of Benefits a bill?

The EOB is not a bill. Rather, it is an explanation of how your claim has been processed. Please click here for more information.

What if I do not agree with a claims denial?

You may ask for Tokio Marine HCC - MIS Group to reconsider the denial by submitting a request for an appeal in writing within 90 days. In order for the claims department to review the appeal, you must supply additional documentation to support a reversal of the denial.

For complete benefits, please refer to your plan.

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