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Thank you, your online claim has been submitted for processing. However, your claim has also been randomly selected for Audit. For more information on the Audit Process, please see the Terms and Conditions.
Audit Confirmation Number 210611-249728-00
Submission Date: June 21, 2011
Plan Member: THAILA RIDEN
Plan Number: 275852
ID Number: E000000016
To help us complete our audit, please follow the steps below and send us the required information by
:
Step 1:
Select view/print to obtain a copy of the summary of your online claim submission.
Step 2:
Attach your original claim receipts and any supporting documentation to your claim summary statement. (If you do not have a printer, please write your Audit Confirmation Number on each receipt.) Please note, your receipts will become part of our audit record and therefore, will not be returned to you.
Step 3:
Mail to:
The Great-West Life Assurance Company eClaims Service P.O. Box 11647 Stn Centre Ville, Montreal QC H3C 6A9
Step 4:
You must acknowledge by checking the appropriate box that failure to comply with this audit request will result in cancellation of online claim privileges and you will be required to repay any money paid to you for this claim. You also authorize Great-West Life to request additional information from the provider of service as deemed appropriate in the assessment and verification of the submitted claim(s).
If you require assistance, please call
1-855-623-2998
.
Audit Terms and Conditions
•
Great-West Life routinely audits claims. If your claim is selected for audit, it may still be processed and paid. However, it is important that you follow all instructions carefully and respond by the deadlines provided to help ensure that future claims are not affected.
If your claim is selected for audit:
you will either receive audit notification onscreen during the claim process immediately after you submit your claim, or by mail after your claim is submitted.
if you cannot meet the audit deadline, please contact us to discuss a possible extension to avoid suspension of online submission privileges and/or a requirement that you repay the claim(s).
if the audit finds that your claim was underpaid, the auditor will request an adjustment be paid to you. Conversely, if there is an overpayment, you will be responsible to repay the amount of the overpayment.
Great-West Life reserves the right to:
remove your access to online submission at its discretion without prior notification or explanation.
decline your claim submission if you provide false, incomplete or misleading information.
classify your claim as an overpayment, remove submission privileges and / or notify your Employer or Plan Sponsor if you fail to respond to an audit request.
take all possible action to recover an overpayment.
verify the accuracy of all information provided by you either online or during a claim audit with your provider.
request additional information from your provider as deemed appropriate in the assessment and verification of your claim(s).
Summary - Online Claim Submission
Confirmation Number
210611-249728-00
Claim Details -
Vision
Service Date
Service Type
Amount Paid
16 Jun 2011
Contact Lenses
253.16
$
TOTAL AMOUNT PAID:
Provider:
Patient:
THAILA RIDEN, Member
Is child a full-time Student?
No
Is a Claim being made for Workers Compensation benefits?
Has the claim been submitted to or paid in part by another group plan?
Are you, or any other members of your family, entitled to benefits under any other group plan for the
expenses being claimed?
Insurance Company:
Great-West Life
Plan Number:
ID Number:
Spouse/Partner's Month and day of Birth:
Reason for Purchase:
Other
Did you receive a physician's referral for this expense?
Is the treatment required as the result of an accident?
Is the claim for dentures, crown or bridge?
Is this the initial placement?
Give date of prior placement:
I certify that the given information is true, correct and complete to the best of my knowledge. Submission of fraudulent claims will result in notification to your Employer or Plan Sponsor. In the event of a fraudulent claim submission, a criminal complaint will be submitted to the appropriate law enforcement agency when deemed appropriate.
For claim audit purposes you must retain all original claim receipts and supporting documentation for at least 12 months.
On the Web
Mailing Address
Telephone
Visit us at our personalized secure service site for plan members at www.greatwestlife.com
Winnipeg Benefit Payments P.O. Box 3050 Winnipeg Manitoba R3C 0E6
