Use the information below to help settle your claim as fast as possible. You do not need to file a separate claim for each bill – just file one claim for each incident. If you receive more bills after you file the claim, include the plan sponsor, policy number and patient’s name when you send them to us.
Please note: Written notice of a claim must be received within 20 days of a loss or injury. The completed claim form and supporting documents must be submitted to the claims department within 90 days of the occurrence using the instructions on the claim form.
Primary medical accident coverage claim form – The plan sponsors should submit the claim to Nationwide Insurance first, not the person’s primary insurance company.
Excess medical accident coverage claim form – The plan sponsor should submit the claim to the insured’s primary insurance company first. Any remaining charges will be considered after payment has been made and an Explanation of Benefits has been submitted. If no other insurance exists, a written statement from the patient or parent’s employer(s) must be obtained, verifying that no other coverage exists.
Death and specific loss coverage claim form – In the event of a death or specific loss (loss of limb, hand, sight, etc.), the plan sponsor must submit this form to Nationwide, along with the appropriate primary or excess claim form.
Nationwide volunteer emergency group claim form – Use this form for injuries, death or specific losses (limb, hand, sight, etc.) that occur during a group-sponsored activity.
Volunteer emergency group claim form (Indiana) – Use this form for injuries, death or specific losses (limb, hand, sight, etc.) that occur during an Indiana volunteer emergency group-sponsored activity.
How to complete the claim form
- The Organization Certification section must be completed and certified by an official of the plan sponsor. Proof of membership or certificate of coverage may be submitted in place of the plan sponsor’s signature, if applicable. The official cannot be the agent, broker or anyone related to the patient. The policy number must be included.
- Have the insured (or parent or guardian if the insured is a minor) complete Section II.
- Assignment of benefits is optional. The signature of the patient (or parent, if patient is a minor) is required if the payment is requested to be made directly to the provider or medical services. If an assignment isn't made, the provider may have assignment on file. In this case, proof of payment in full is required before the reimbursement can be made to the patient or parent.
- Date and sign Section III (optional).
- Attach itemized bills showing the patient’s name, diagnosed condition, date(s) of treatment, nature of treatment and charge per treatment.
- Include the Explanation of Benefits from the primary insurance carrier, if applicable.
- Send all documentation to:
Nationwide Specialty Insurance
PO Box 420
Springfield, MA 01101
How to check the status of a claim
To check the status of a claim, contact the claims department at 1-800-525-8669.
If all representatives are busy, leave a detailed message including:
- Insured's name
- Phone number with area code
- Patient name, if different from insured
- Member number, if applicable