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How to Submit a Claim

Filing a claim is easy.

 
OPTION 1: PROVIDER SUBMISSION

The most common way to file a claim is to present your Select Benefits ID card to your provider at the time of service. Ask your provider to accept an assignment of your benefits and to bill Select Benefit Administrators (SBA) directly. Your provider is under no obligation to do this. In that case, file the claim yourself as instructed below.
 
If your provider agrees to bill SBA, the benefit will be paid to them and you’ll be sent an Explanation of Benefits a few weeks later showing what was paid. Any charges that remain after SBA has paid the provider are your responsibility.

OPTION 2: EMPLOYEE SUBMISSION

If you paid your provider at the time of service, you may submit a claim to SBA using a Select Benefits Claims Form. SBA will then pay benefits directly to you based on the amount covered by your Select Benefits Plan. You will need a signed Authorization for Release of Medical Information form and an itemized bill from the provider listing patient name, dates of service, procedure and diagnosis codes. SBA cannot process your claim without CPT/procedure codes and ICD9/diagnosis codes.

Ask your provider for Health Care Financing Administration (HCFA) claim forms and UB92 forms if you are seen at a hospital.
 
An Explanation of Benefits from another insurance plan isn’t an acceptable receipt.

Mail or fax the form to:
Select Benefit Administrators 
Attention: Claims Department
P.O. Box 440
Ashland, WI 54806
Fax: (715) 682-5919
Phone: 1-800-497-3699

    LIFE INSURANCE CLAIMS
     

    If an insured dies while covered under the group policy’s life insurance benefit, please call a Select Benefit Administrators claims representative at 1-800-497-3699.




    Select Benefits insurance policies are not a replacement for a major medical policy or other comprehensive coverage. They are designed to provide benefits at a preselected, fixed-dollar amount. Coverage may be subject to exclusions, limitations, reductions, and termination of benefit provisions. Select Benefits policies are insured by Symetra Life Insurance Company located at 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004, and are not available in all U.S. states or any U.S. territory.

     




    CLAIMS FORM
     
    Copyright © 2004 - Symetra Life Insurance Company, 777 108th Ave NE, Suite 1200, Bellevue, WA 98004. All rights reserved. Symetra® is a registered service mark of Symetra Life Insurance Company.
    Customers may access their account information from this site. Other information in this site may be pending approval for use in states with website filing requirements.