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Required, They Should Be Sent To Our National Document Center at P.O. Box 258806, Oklahoma City, OK 73125-8806

This document is a letter from Bristol West Insurance to Theo Hersperger regarding a claim. It requests important Medicare information to comply with federal regulations regarding coordination of benefits. Specifically, it asks for Mr. Hersperger's Social Security number or Medicare claim number to submit to the Centers for Medicare and Medicaid Services. An attached form provides spaces for this information, as well as his Medicare enrollment status and signature, to assist Bristol West in meeting its mandatory reporting obligations.

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Theo Hersperger
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191 views3 pages

Required, They Should Be Sent To Our National Document Center at P.O. Box 258806, Oklahoma City, OK 73125-8806

This document is a letter from Bristol West Insurance to Theo Hersperger regarding a claim. It requests important Medicare information to comply with federal regulations regarding coordination of benefits. Specifically, it asks for Mr. Hersperger's Social Security number or Medicare claim number to submit to the Centers for Medicare and Medicaid Services. An attached form provides spaces for this information, as well as his Medicare enrollment status and signature, to assist Bristol West in meeting its mandatory reporting obligations.

Uploaded by

Theo Hersperger
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

Phone: (954) 585-5419

Fax: (855) 822-3139


Email: docs@bristolwest.com
Please include your claim # on any correspondence
Bristol West Insurance
P.O. Box 258806
August 28, 2023 Oklahoma City, OK 73125-8806

THEO HERSPERGER
928 OLIVE TREE CIR
GREENACRES FL 33413-3056
Delivered by email to: Theo.hersperger06@gmail.com

RE: Insured: Cathy Venencia


Claim Number: 7006314490-1-6
Policy Number: G012290293
Loss Date: 07/13/2023
Injured Party: Theo Hersperger
Subject: Request for Important Information

Dear Mr. Hersperger:

The Federal government requires that insurance companies obtain and report information to the Centers
for Medicare & Medicaid Services (CMS), a government agency. This information helps Medicare properly
coordinate its payments with any other insurance or benefits you may have.

As of the date of this letter, we have not received your Social Security Number or Medicare Claim Number.
Please complete the attached form and return it to us immediately to ensure compliance with current Medicare
regulations.

If you have questions about our request, please visit CMS' website at http://www.cms.gov/Medicare/
Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/
Overview.html or contact Medicare directly at (800) 633-4227.

If you have questions about your claim, please contact me at the number shown below.

Thank you for your cooperation and allowing us to be of service.

Sincerely,
James Welch
Claims Supervisor
(954) 585-5408
Security National Insurance Company
Email communications are preferred and should be sent to docs@bristolwest.com. If hard copies of communications are
required, they should be sent to our National Document Center at P.O. Box 258806, Oklahoma City, OK 73125-8806.

LFWD1Z3M3
Page 1 of 2

The Centers for Medicare & Medicaid Services (CMS) is the federal agency that oversees the Medicare
program. Many Medicare beneficiaries have other insurance in addition to their Medicare benefits. Sometimes,
Medicare is supposed to pay after the other insurance. However, if certain other insurance delays payment,
Medicare may make a “conditional payment” so as not to inconvenience the beneficiary, and recover after the
other insurance pays.
Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA), a new federal
law that became effective January 1, 2009, requires that liability insurers (including self-insurers), no-fault
insurers, and workers’ compensation plans report specific information about Medicare beneficiaries who have
other insurance coverage. This reporting is to assist CMS and other insurance plans to properly coordinate
payment of benefits among plans so that your claims are paid promptly and correctly.
We are asking you to the answer the questions below so that we may comply with this law.

Please review this picture of the


Medicare card to determine if
you have, or have ever had, a
similar Medicare card.

Section I

Are you, or have you ever been, enrolled in Medicare Part A, B, C or D? Yes No
Full Name: (Please print the name exactly as it appears on your SSN or Medicare card if available.)

Medicare Beneficiary Identifier Date of Birth _ _


(no dashes) (Mo/Day/Year)
Social Security Number: _ _
Sex Female Male
(If Medicare Beneficiary Identifier is Unavailable)
**Note: If you are uncomfortable with providing the full Social Security Number (SSN), you have the
option to provide the last 5 digits of the SSN in the section above

Section II
I understand that the information requested is to assist the requesting insurance arrangement to accurately
coordinate benefits with Medicare and to meet its mandatory reporting obligations under Medicare law.

7006314490-1-6
Injured Party or Injured Party Representative Signature Claim Number

Name of Person Completing This Form If Injured Party is Unable (Please Print)

Signature of Person Completing This Form Date

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Page 2 of 2

If you have completed Sections I and II above, stop here. If you are refusing to provide the information requested in Sections I
and II, proceed to Section III.

Section III

7006314490-1-6
Injured Party Name (Please Print) Claim Number

For the reason(s) listed below, I have not provided the information requested. I understand that if I am a
Medicare beneficiary and I do not provide the requested information, I may be violating obligations as a
beneficiary to assist Medicare in coordinating benefits to pay my claims correctly and promptly.

Reason(s) for Refusal to Provide Requested Information:

Signature of Person Completing This Form Date

LFWD1Z3M3

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