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EXLService.com, LLC. will be contracted by your health plan to review cases that at the outset indicate a potential case for subrogation. Subrogation is the contractual and equitable right to recover any payments paid for health care expenses which were the result of injuries caused by another person or entity who has been determined or has accepted responsibility for these health care benefits.

When you or one of your dependents receives health care benefits for injuries/illness caused by another person or entity, we will seek recovery of benefits paid. You are asked to assist us by identifying the party responsible for your accidental injury.

1.1 Purpose

The purpose of this questionnaire is to gather enough information about the incident to decide whether to continue with a full investigation.

Please be advised that this is a routine process to gather preliminary information, and we assure you that further disclosure will be on a restricted need-to-know basis only.

2 Accessing the Online Questionnaire

To access the online questionnaire, follow these steps:

Open any compatible browser.
Type the URL provided.
Select English from the language options. An overview about Subrogation and how it works will be displayed. You can read through this for a better understanding on how to fill the questionnaire accurately.
Click the Proceed to Login
Type the case ID in the Case ID text box. If you do not know your case ID, refer to the alphanumeric code under the barcode on top of the letter you received by mail.
Type your last name in the Member Last Name text box.
Click the Go to Survey
Click the Click for questionnaire The online questionnaire will appear. If you click Cancel, a confirmation message appears. Click OK to exit the questionnaire.

3 Filling the Online Questionnaire

3.1 Question 1

Select Yes or No from the drop-down list, if your medical treatment was as a result of an accident or injury?

If you select Yes from the drop-down list, proceed to Question 2.
If you select No from the drop-down list, click the Submit button to submit the form.

3.2 Question 2

Select how the accident or injury was caused. Click the appropriate option. You can select multiple options that best suits your case.

Motor Vehicle
Motorcycle
Work Related
Sports Related
At Home
Medical Malpractice
Caused by another Party
Occurred On Another Property
Other

3.3 Question 3

In the description text box provided, explain the details of the accident or injury with the date and location.

3.4 Question 4

Type the name of the state in which the accident or injury occurred.
Select the date from the calendar picker on which the accident or injury occurred.

3.5 Question 5

Complete the following questions only if the accident or injury was caused by another person or entity or occurred on another person’s property. Otherwise, proceed to Question 6.

Type the name and address of the person responsible or entity in the text box provided.
Select Yes or No from the drop-down list if you had reported the accident or injury. If you select Yes, type the relevant information in the To whom did you report it text box. If you select No, proceed to the next question.
Type the person or entity’s insurance company name in the text box provided.
Select Yes or No from the drop-down list if you have filed a claim with other party’s insurance company. If you select Yes, provide the Adjuster’s details. Otherwise, proceed to Question 6.
Type the claim number in the Claim # text box.
Type the address in the Address text box.
Type either the city, state or zip code in the City/State/Zip text box.
Type the phone number in the Phone text box.
Type the fax number in the Fax text box.

3.6 Question 6

Complete the following questions only if you were on the job (work-related) when the accident or injury occurred or if it is related to your employment.

Type the name of the employer in the Employer’s Name text box.
Type the employer’s address in the Address text box.
Type either the employer’s city, state or zip code in the City/State/Zip text box.
Type the employer’s phone number in the Phone text box.
Type the employer’s fax number in the Fax text box.
If you had filed the report of injury, select the current status from the following:

Filed Claim
Claim Denied
Denial Appealed

If you were injured while you were on the job when the accident or injury occurred or if it is related to your employment, provide the Workers’ Compensation Carrier details:
Type the name of the Workers’ Compensation Carrier in the text box provided.
Type the address in the Address text box.
Type either the city, state or zip code in the City/State/Zip text box.
Type the claim number in the Claim # text box.
Type the name of the adjuster in the Adjuster’s Name text box.
Type the phone number in the Phone text box.
Type the fax number in the Fax text box.

3.7 Question 7

3.7.1 Question 7a

Complete the following questions if there was an auto accident.

Select from the following options if you were the,
Driver
Passenger
Pedestrian
Select whether the auto accident was occurred due to
Single Vehicle
Multiple Vehicles
Provide the name of your auto insurance company details:
Type the name of your auto insurance company details in the Your auto insurance company name is text box.
Type the policy number in the Policy # text box.
Select Yes or No if you have you filed a claim from the Have you filed a claim drop-down list. If you select Yes, provide the following information. Otherwise, proceed to Question 7b.
Type the claim number in the Claim # text box.
Type the name of the adjuster in the Adjuster’s Name text box.
Type the address in the Address text box.
Type either the city, state or zip code in the City/State/Zip text box.

3.7.2 Question 7b

Complete the following questions if another vehicle was responsible for the accident or injury.

Type the name of the owner of the other vehicle in the Owner of the Vehicle text box.
Type the address of the other vehicle’s owner in the Address text box.
Type the name of the auto insurance company of the other vehicle in the Insurance Company text box.
Type the address of the insurance company in the Address text box.
Select Yes or No if you have filed a claim with the other vehicle’s insurance company. If you select Yes, provide the following information. Otherwise, proceed to Question 8.
Type the name of the adjuster in the Adjuster’s Name text box.
Type the address in the Address text box.
Type either the city, state or zip code in the City/State/Zip text box.
Type the phone number in the Phone text box.
Type the fax number in the Fax text box.

3.8 Question 8

Complete the following questions if you are represented by an attorney for this accident or injury.

Type the name of the attorney in the Attorney’s Name text box.
Type the firm name in the Firm Name text box.
Type the phone number in the Phone text box.
Type the fax number in the Fax text box.
Type the address in the Address text box.
Type either the city, state or zip code in the City/State/Zip text box.

3.9 Question 9

Select Yes or No from the drop-down list if you are still being treated. If you select Yes, proceed to Question 10. If you select No, type the date on which the treatment was ended.

3.10 Question 10

Provide the name of the prescription drugs associated with the treatment for injuries in this accident in the text box provided.

3.11 Question 11

Complete the following questions if you had received any settlement money or insurance money for this accident or injury other than from your health plan.

Type the amount paid to you by the other party other than your health plan in the Amount Paid text box.
Type the name of party other than your health plan in the Who Paid text box.
Type the date or select the date from the Date Payment was received calendar picker on when the payment was received.

3.12 Question 12

Type any comments in the text box provided.

4 Submitting the Questionnaire

Read the Subrogation Assignment and Reimbursement Agreement and then click the Submit button. On submission, your answers will be automatically submitted safely to our offices.

Table of Contents

1 Introduction