Signature Services

International Medical Insurance Coverage

2024-2025

Contact VISIT Insurance by Email: signatureservices@visitinsurance.com or by Phone: 1-703-660-9062

BENEFIT SUMMARY

COVERAGES

Medical Maximums per Injury or Illness

Lifetime Maximum

COVID-19

TELADOC
Common issues treated through Teladoc includes: allergies, bronchitis, cold and flu symptoms, respiratory infections, skin problems, sinus problems, and much more.

Click here to Get Started

Deductible per Period of Coverage
*For a covered medical expense, the Deductible is the portion of your medical bill that is your responsibility to pay to the doctor or hospital.

Deductible – Emergency Room
(applies only to Emergency Room visits)

COPAYS

COINSURANCE

Pre-existing Conditions

Hospital Room and Board

Local Ambulance

Intensive Care Unit

Outpatient Treatment

Mental Health Disorders

Prescription Drugs

Physical Therapy

Team/Club/League Sports
(Collision Sports are excluded from this coverage. The following sports are NOT covered American football, boxing, ice hockey, lacrosse, full contact martial arts, rodeo, rugby and wrestling.)

Adventure Sports/Hazardous Sports

Dental Treatment due to Accident

Dental Treatment to alleviate pain

Emergency Medical Evacuation
(not subject to Deductible or Coinsurance)

Repatriation of Remains
(not subject to Deductible or Coinsurance)

Emergency Reunion
(not subject to Deductible or Coinsurance)

Political Evacuation
(not subject to Deductible or Coinsurance)

Terrorism
(not subject to Deductible or Coinsurance)

Accidental Death and Dismemberment
(not subject to Deductible or Coinsurance)

Incidental Home Country Coverage

Travel Assistance

2024-2025 Policy Documents

BENEFITS

$250,000 per illness or injury

$5,000,000 Lifetime
When the Lifetime Maximum is reached, no further benefits, reimbursements or payments will be available under this insurance.

Special Note regarding Alcohol-Related Illness or Injury: Illness or Injury sustained as the result of being under the influence alcohol, liquor, intoxicating substances, narcotics or drugs are excluded on the policy.

COVID-19, the disease caused by the novel coronavirus, generally WILL be covered as would any other illness under the MOUNTBATTEN PROGRAM Health Plan, including testing and treatment up to the policy limit. For testing to be covered by the Insurance, you must be symptomatic. Please be sure your Doctor’s Office submits your test as a SICK visit. If the test is submitted as a Preventive Care visit the claim will be denied.

Call 1-800-TELADOC (835-2362) or visit www.teladoc.com to access the TELADOC services – Service is FREE! With TELADOC you can be connected with a licensed physician in minutes, not hours or days like you would at the ER, Urgent Care, or with your Doctor. And, you can get care from wherever you are home, work or traveling.

Except for Emergency Room, $100 per Illness or Injury.

Subject to $500 but only if no in-patient admission

The $500 ER Deductible applies to illnesses only, and only those illness that do not result in hospital admission. If the ER visit is due to an Injury, the $500 Deductible does not apply. (For an Injury, the standard $100 Deductible would apply.)

Urgent Care - $50
Walk-in Clinic - $20
(Deductible does not apply when there is a co-pay)

In-Network: Plan pays 90%

Out-of-Network: Plan pays 80% of Eligible Medical Expenses, up to the Maximum Limit.

(maximum out-of-pocket resets after 12 months from the coverage start date)

Charges resulting directly or indirectly from or relating to any Pre-existing Condition that existed within thirty-six (36) months prior to the Effective Date are excluded until the Insured Person has maintained twelve (12) months of continuous coverage under this insurance.

• Period of Coverage Limit (after 12 months): $500
• Maximum Limit: $1,500

Average Semi-Private room rate, including nursing services

Illness: Paid at 100% for an illness resulting in hospitalization
Eligible Medical Expenses are limited to Usual, Reasonable and Customary Charges Subject to Deductible

Usual, Reasonable and Customary Charges

Inpatient Mental or Nervous / Substance Abuse
• Maximum Limit: $10,000
• Not covered if incurred at the Student Health Center

Outpatient Mental and Nervous / Substance Abuse
• Maximum Limit per day: $50
• Maximum Limit: $500

90% Reimbursement -
Usual, Reasonable and Customary Charges
Covered as a medical expense and is subject to the Deductible and co-insurance. If the medical condition is covered, the prescriptions will also be covered. Prescriptions are a reimbursable expense. You will need to pay for your prescription first and then complete a claim form to be reimbursed. Click here to download a copy of the card to be used at your local pharmacy.

Click here to compare prices for your prescription.

Limit one visit per day
Medical order or Treatment plan required
Usual, Reasonable and Customary Charges

NO COVERAGE

$50,000 Lifetime Maximum
Adventure Sports includes the following: abseiling, BMX, bobsledding, bungee jumping, canyoning, caving, hang gliding, heli-skiing, high diving, hot air ballooning, inline skating, jet skiing, jungle zip lining, kayaking, mountain biking, parachuting, paragliding, parascending, piloting a non-commercial aircraft, rappelling, rock climbing or mountaineering (ropes and guides to 4500m from ground level), scuba diving (to 50m), skydiving, snorkeling, snowmobiling, spelunking, surfing, trekking, whitewater rafting (to Class V), and wildlife safaris, and windsurfing.

$500 Maximum per Certificate Period, No Maximum per Tooth

$350 Maximum per Certificate Period

$,000 per Participant Lifetime Maximum
Please call 1-317-655-4500 for Emergency Medical Evacuation requests. All details must be coordinated with Assist to be eligible for coverage.

$25,000 Maximum
Cremation/Burial: $5,000 maximum
Please call 1-317-655-4500 for Emergency Medical Evacuation requests. All details must be coordinated with Assist to be eligible for coverage.

$15,000 Lifetime Maximum
Please call 1-317-655-4500 for Emergency Medical Evacuation requests. All details must be coordinated with Assist to be eligible for coverage.

$10,000 Lifetime Maximum
Please call (317) 655-4500 for Emergency Medical Evacuation requests. All details must be coordinated with Assist to be eligible for coverage.

$50,000 Lifetime Maximum
Please call 1-317-655-4500 for Emergency Medical Evacuation requests. All details must be coordinated with Assist to be eligible for coverage.

$25,000 per Participant

14 days

24-Hour Worldwide Assistance Services:
1-866-799-8270/ 1-317-927-6896

2024-2025 Policy Documents

TELADOC

Call 1-800-TELADOC (835-2362) visit www.teladoc.com
Access TELADOC services – Service is FREE!

TELADOC Service is FREE! With TELADOC you can be connected with a licensed physician in minutes, not hours or days like you would at the ER, Urgent Care, or with your Doctor. And, you can get care from wherever you are home, work or traveling. Common issues treated through Teladoc includes allergies, bronchitis, cold and flu symptoms, respiratory infections, skin problems, sinus problems, and much more. Click here to Get Started

TELADOC should be used for NON-EMERGENCY health issues ONLY! To set-up your account, please go to www.teladoc.com or download the APP. When setting up your account, please use the IMG Insured ID Number listed on the attached ID card and Zip Code 46208.

Adventure Sports Coverage

COVID-19 Coverage

COVID-19, the disease caused by the novel coronavirus, generally WILL be covered as would any other illness under the Mountbatten Health Insurance policy, including testing and treatment up to the policy limit.

COVID-19 TESTING - COVID-19 Testing is only covered if you are symptomatic. The test will not be covered for travel or non-illness related testing. Your doctor must submit the COVID-19 test as a “sick visit” and provide the medical records when submitting your claim. You should also submit a Patient Claim Form through your MyIMG Account explaining your symptoms.
COVID-19 VACCINES - Vaccines are currently being offered for FREE at most facilities. An administrative fee may apply. The COVID-19 vaccine is NOT covered on your Mountbatten Health Insurance Patriot Exchange Plan.
COVID-19 TREATMENT - If you test positive for COVID-19, your medical expense will be covered by the UnitedHealthcare Plan up to the policy maximum of $250,000.

If you are experiencing symptoms related to COVID-19, it is important that you first contact your doctor or urgent care facility by phone to review the proper protocol to receive a test and treatment for COVID-19. Be sure to follow the current CDC Guidelines.

When going to the doctor, please be sure to take your UnitedHealthcare Insurance card

How To Set-up Your MYIMG Account

MyIMG

Service at your fingertips anytime, anywhere - that’s what MyIMG provides. MyIMG is our proprietary online service that allows you to access information and manage your IMG accounts, 24 hours a day, seven days a week, from anywhere in the world. Our service centers in the U.S. and Europe are always available to help or handle emergencies 24 hours a day, but through MyIMG you have immediate access to a wealth of information about your account and can manage routine areas to help you save time when you may need it most. Some features include:

Get explanation of benefits
Initiate precertification
Obtain certificate documents
Locate a provider
Recommend a provider/facility
Request or print ID cards
Submit a Claim online
Check the status of a Claim

Don't have an account? Create an account

You will need to put in your Health Insurance ID Number and Date of Birth to set-up an account. If you do not have your Health Insurance ID Number, please contact our office at 703-660-9062

Important Insurance Terms

What is a Deductible?
For a covered medical expense, the deductible is the portion of your medical bill that is your responsibility. The deductible will first be subtracted from the total medical bill and you will need to pay this portion directly to the doctor or hospital.

The deductible is “per illness or injury,” not per visit to the doctor. This means if you have to go to the doctor more than once for the same illness or injury, you will only need to pay the deductible one time.

Your deductible is $100 per illness or injury. The Emergency Room deductible is $250 per ER visit.

What is Co-insurance?
Coinsurance is the term used by health insurance companies to refer to the amount that you are required to pay for a medical claim, apart from the deductible. Your plan pays 100% of Eligible Medical Expenses subject to Usual, Reasonable and Customary charges.

Charges above Usual, Reasonable and Customary will be your responsibility. You are strongly encouraged to utilize the independent Preferred Provider Organization (PPO) network to avoid being responsible for medical expenses over and above Usual, Reasonable and Customary.

How do I Pay for My Prescriptions?
Your Plan includes a Discount Prescription Drug Benefit through Universal Rx. When going to a pharmacy, please present the AWEUSA Plan ID Card, the prescription discount information is included on the right side of the card. If the prescription is eligible for a discount, it will be applied at the time of your purchase. If there is a remaining cost due after any discount, please pay the remaining balance to the pharmacy and keep the receipt. To be reimbursed for the remaining balance of the prescription cost, please submit a PATIENT Claim Form with your receipt and a copy of your prescription. The deductible of $100 per illness or injury applies.

Important Information: Universal Rx Pharmacy Help Desk: 1-800-329-0988 or www.imgpoc.com

What is a pre-existing condition?
Charges resulting directly or indirectly from or relating to any Pre-existing Condition that existed within thirty-six (36) months prior to the Effective Date are excluded until the Insured Person has maintained twelve (12) months of continuous coverage under this insurance.

• Period of Coverage Limit (after 12 months): $500
• Maximum Limit: $1,500

Definition of Pre-existing Condition as defined by the Certificate:

“Pre-existing Condition: Any Injury, Illness, sickness, disease, or other physical, medical, Mental or Nervous Disorder, condition or ailment that, with reasonable medical certainty, existed at the time of Application or at any time during the three (3) years prior to the Effective Date of this insurance, whether or not previously manifested, symptomatic or known, diagnosed, Treated, or disclosed to the Company prior to the Effective Date, and including any and all subsequent, chronic or recurring complications or consequences related thereto or resulting or arising therefrom.”

What is Precertification?
Precertification is a requirement under your certificate for certain medical services. Pre-certification is a general determination of medical necessity only, not an assurance of coverage, verification of benefits or a guarantee of payment.

The following must always be precertified for medical necessity before admission or receiving the treatments and/or supplies:

Any treatment requiring inpatient hospitalization
Surgery or surgical procedure, including outpatient surgery
CAT scans or MRI's
Care in an extended care facility
Home nursing care
Chemotherapy
Radiation Therapy
Interfacility Ambulance Transfer

During the precertification process, medical professionals review the planned medical services against standard medical criteria to ensure that the services are within accepted medical standards and are medically necessary.

Precertification may be initiated by you, your representative or your medical provider. This can be done through MyIMG, through the Client Resources page of www.IMGLOBAL.com or by calling IMG at 1-317-655-4500.

Most U.S. hospitals and physicians are familiar with the precertification process and will make the phone call for you, though they are not required to do this. You are responsible for ensuring the precertification process is done five days before you are hospitalized or within 48 hours after an emergency admission to the hospital.

Click here to submit a Precertification online

What is a Reasonable & Customary charge?
A Usual, Reasonable & Customary (URC) charge is the amount normally charged by medical service providers for similar services and supplies within the geographic area in which the charge is incurred.

What is Medical Evacuation?
Medical Evacuation means transferring the insured person to the nearest hospital or medical facility in case of an emergency injury or sickness or back to his/her home country. It can be done by any necessary means of transportation.

What is Repatriation?
In case of death, the Repatriation benefit covers the transportation of your remains back to your family and your home country.

Are Injuries from Sports Covered?
Recreational sports only are covered through the regular medical coverage. Should you need coverage for Hazardous/Adventure Sports Click Here to order the Patriot Plan, please be sure to include the Adventure Sports Rider when purchasing. When purchasing coverage, please be sure that your particular sport is covered.

Is there Dental Coverage?
There is limited coverage for dental pain and injury to natural teeth on your policy.

Relief of sudden and unexpected pain to sound, natural teeth, including but not limited to fillings will be covered up to $350 maximum. Injury due to an accident will be covered up to $500 per Accident maximum.

Do I need a referral to go to a Specialist?
A doctor’s referral typically is not required. If you have a special medical condition, we recommend that you check with the Claims Office 1-317-655-4500 prior to making an appointment with a Specialist.

Where Can I Find a Doctor or Hospital?

What are the Provider Networks?
A provider network is a list of the doctors, other health care providers, and hospitals that a plan contracts with to provide medical care to its members. These providers are called “network providers” or “in-network providers.” A provider that isn't contracted with the plan is called an “out-of-network provider.”

When contacting a doctor or hospital, please be sure to let them know that you are in the United Health Care (PPO) Network.

How do I search for a local doctor or hospital?
To search for a medical care provider within the United Health Care (PPO) network, please go to:

United Health Care

How to File a Claim

Where do I find my Insurance ID Number?
Your ID Number is located on your Insurance Card.

What do I do if I lose my ID Card?
Please contact VISIT at 1-703-660-9062 or by email at jeffersonstate@visitinsurance.com. Be sure to let us know that you are in the Signature Services program. You can also print your ID Card by going to your MyIMG account.

Do I need to go to a specific doctor or hospital if I need medical attention?
You are strongly encouraged to search for doctors or hospitals that utilize the United Health Care (PPO) network. Refer to 'Where Can I Find a Doctor or Hospital?' for details.

If an emergency:
• Go directly to the hospital, or call 911 for emergency response
• Call the 24-hour assistance service center at the number listed on your ID card to alert the center of your situation. 1-317-655-4500.

Precertification
Precertification is a requirement under your certificate for certain medical services. Pre-certification is a general determination of medical necessity only, not an assurance of coverage, verification of benefits or a guarantee of payment.

The following must always be precertified for medical necessity before admission or receiving the treatments and/or supplies:

Any treatment requiring inpatient hospitalization
Surgery or surgical procedure, including outpatient surgery
CAT scans or MRI's
Care in an extended care facility
Home nursing care
Chemotherapy
Radiation Therapy
Interfacility Ambulance Transfer

During the precertification process, medical professionals review the planned medical services against standard medical criteria to ensure that the services are within accepted medical standards and are medically necessary.
Precertification may be initiated by you, your representative or your medical provider. This can be done through MyIMG, through the Client Resources page of www.IMGLOBAL.com or by calling IMG at 1-317-655-4500.

Most U.S. hospitals and physicians are familiar with the precertification process and will make the phone call for you, though they are not required to do this. You are responsible for ensuring the precertification process is done five days before you are hospitalized or within 48 hours after an emergency admission to the hospital.

Click here to submit a Precertification online

Do I Need To Submit A Claim Form?

ONLINE CLAIM SUBMISSION PROCESS

CLAIM FORMS: There are TWO (2) different claim forms, and BOTH ARE REQUIRED FOR EACH SEPARATE CLAIM. There is a DOCTOR claim form that must be completed and submitted by the doctor/hospital/medical provider. There is a PATIENT claim form, that must be completed and submitted BY YOU. If the insurance company does not receive BOTH completed claim forms, they will not begin to process your claim.

PATIENT Claim Form
The PATIENT Claim Form can be downloaded or alternatively you can submit your claim online through your MyIMG Account. (You may also submit a completed PATIENT Claim Form by email: customercare@imglobal.com or fax: 1-317-655-4505). The PATIENT Claim Form must be submitted within 90 days of treatment. All documents from you and your doctor must be received within 180 days to process your claim.

DOCTOR Claim Form
Be sure your Doctor files your claim through UnitedHealthcare using the information found on your ID Card. This will allow your doctor to file your claim electronically which will help expedite the claims process. Your ID card includes a Member ID Number and a Group Number your Doctor must use to file the claim properly. Improperly filed claims may be delayed or denied. Should your Doctor’s Office have any questions, please have them call UnitedHealthcare directly at: 1-888-543-1238.

UnitedHealthcare Member ID: xxxxx
(This number is found on your ID Card and is unique for each person)

Group Number: 76570070
(This number is the same for all Signature Services Students)

Payor ID: USN01
(This number is the same for all Signature Services Students)

DOCTOR CLAIM FORMS can be filed electronically to UnitedHealthcare or mailed to:
UHC Global
P.O. Box 30526
Salt Lake City, UT

84130-0526
(This address is only for the Doctor’s Office to submit their Claim Forms)

PRESCRIPTIONS: In addition to your SIGNATURE SERVICES Health Plan ID card, attached is your Prescription Discount Card for your medications. When going to a pharmacy, please present the SIGNATURE SERVICES PROGRAM HEALTH Plan ID Card, the prescription discount information is included on the right side of the card. If the prescription is eligible for a discount, it will be applied at the time of your purchase. If there is a remaining cost due after any discount, please pay the remaining balance to the pharmacy and keep the receipt. To be reimbursed for the remaining balance of the prescription cost, please submit a PATIENT Claim Form with your receipt and a copy of your prescription. The deductible of $100 per illness or injury applies.

For faster service on your claim, we suggest that you use the MyIMG system online to submit your claim.

Where do I send my Claim Form?

Click here to download a CLAIM FORM

Mail PATIENT CLAIM Forms to:
International Medical Group, Inc.
Claims Department
PO BOX 240429
Apple Valley, MN 55124
Phone: 1-317-655-4500
Fax: 1.317.655.4505
Email: customercare@imglobal.com

How do I check the status of a claim?

Log into your MyIMG Account and check the Claims tab for updates
Call 1-317-655-4500
Email the Claims Office at customercare@imglobal.com to request an update on your claim. Be sure to include your full name, your IMG ID Number from your health insurance ID card and the date of the doctor's visit that you are requesting an update.

What do I do if the claim is showing as PENDING?
If your Claim is showing as PENDING, please be sure to check the status of the claim on your MyIMG Account to see what information is needed to finalize your claim.

There is no record of my claim
Contact your doctor's office and ask them to submit the claim to IMG. If they say they have already submitted the claim, be sure to verify the address they sent the claim to and the date it was sent. Email this information to customercare@imglobal.com and ask the Claims Office to research their records to see if the claim is in their system. If the Claims Office is unable to locate the claim, please contact your doctor's office and ask them to resubmit the claim. Claims can be mailed to:

UHC Global
P.O. Box 30526
Salt Lake City, UT 84130
Patient to submit a completed IMG Claim Form
You must complete a PATIENT IMG Claim Form to process your claim. This form can be completed online through your MyIMG Account or you can download the IMG Claim Form and mail it or fax it to the claims office.
Charges pending receipt of medical records requested from provider
To process your claim, your doctor must provide the medical records to IMG for your treatment. Please contact your doctor's office and ask them to submit your medical records to the IMG. Medical records can be mailed to:

UHC Global
P.O. Box 30526
Salt Lake City, UT 84130
Your file has been closed due to a lack of response
This means that additional information has been requested but the Claims Office has not received the information. The file can be reopened once the information is received.
In order to process these charges, please submit on a HCFA/UB Form Indicating Standardized procedure (CPT) and Diagnosis (ICD) codes.
These forms are standard forms that doctors use to file a claim with an insurance company. Your doctor should have these forms available. If they are not sure what to file or have questions, please have the them call UHC Global at 1-888-543-1238.

How long do I have to file a claim?

Your IMG PATIENT Claim Form must be submitted to the IMG Claims Office within 90 days of your visit to the doctor, urgent care, emergency room and/or hospital. You and your doctor, hospital and other healthcare and medical service providers and suppliers shall have one hundred eighty (180) days from the date a claim is incurred to submit a complete Proof of Claim, medical records and any additional information needed to process your claim.

IMG Privacy Policy - www.imglobal.com/legal/privacy-policy

How to Pay for My Prescription?

Your SIGNATURE SERVICES Health Plan ID card includes your Prescription Discount information for your medications. When going to a pharmacy, please present the SIGNATURE SERVICES HEALTH Plan ID Card, the prescription discount information is included on the right side of the card. If the prescription is eligible for a discount, it will be applied at the time of your purchase. If there is a remaining cost due after any discount, please pay the remaining balance to the pharmacy and keep the receipt. To be reimbursed for the remaining balance of the prescription cost, please submit a PATIENT Claim Form with your receipt and a copy of your prescription. The deductible of $100 per illness or injury applies.

Prescriptions can be filled at ANY Pharmacy.
Please present your Mountbatten Program Health Plan ID card to the Pharmacy. If the prescription is eligible for a discount, it will be applied when you purchase your prescription. The Universal Rx Discount information is located on the right side of your Health Insurance ID card (as shown below) or you can download a copy of the card by going to https://imgpoc.com.

Please pay any remaining pharmacy costs due after the discount and keep the receipt and a copy of the prescription.

Steps for submitting your CLAIM for REIMBURSEMENT

Complete and submit a PATIENT Claim Form (include your Doctor visit and prescriptions on the same PATIENT CLAIM FORM)
Include a copy of the Receipt.
Include a copy of the Prescription (this can be the Prescription Information that is typically stapled to the prescription bag)
The Claim can be submitted online through your MyIMG Account
Reimbursements are only for covered medical expenses, not for pre-existing conditions. Additional discounts may be available through the pharmaceutical company that manufactures your prescription.)

Important Contact Numbers

Plan Administrator: International Medical Group, Inc. (IMG)

To a Report a Claim, Verify Eligibility or Check on the Status of a Claim Contact:
International Medical Group, Inc.
Claims Department
PO BOX 240429
Apple Valley, MN 55124
Phone: 1-317-655-4500
Fax: 1-317-655-4505
Email: customercare@imglobal.com
24-Hour Worldwide Assistance Services: 1-317-927-6896

Provider Claim Submission:

UHC Global
P.O. Box 30526
Salt Lake City, UT 84130
Telephone: 1-888-543-1238

Preferred Provider Network: United Health Care

Agent: VISIT® International Health Insurance
For answers to General Questions, ID card replacement, General Claims Questions contact your Agent:

VISIT® International Health Insurance
Email: signatureservices@visitinsurance.com
Phone: 1-703-660-9062 Fax: 1-703-991-9164
Office Hours: Monday – Friday, 9am to 6pm USA Eastern Time
Emergency 24/7 Assistance: 1-317-655-4500
After Hours: Please contact us by email at signatureservices@visitinsurance.com

Underwriter: SiriusPoint Specialty Insurance
The AWE Insurance plan is underwritten by SiriusPoint Specialty Insurance. This insurance and its risks are underwritten by the Company as the insurer and carrier, and the Company is solely obligated and liable for the coverage and benefits provided by this insurance.