Please be advised that this policy does not replace your primary

Western New England has purchased an Excess Athletic Accident Insurance policy in the event that a

student-athlete sustains an athletic related injury that will require outside medical treatment. An Injury Claim form

must be submitted by the college to the Athletic Accident Insurance carrier, Mutual of Omaha, in order for the

student-athlete’s bills to be eligible under the plan. Gallagher Student Health & Special Risk (GSHSR) is the

Insurance Broker who administers WNE’s Excess Athletic Accident Insurance policy.

Please be advised that this policy does not replace your primary insurance. All claims must be

submitted through a student’s primary insurance first, as this policy only pays excess to valid and collectible

insurance. An injured student-athlete should provide their primary health insurance information at the time of their

treatment, along with the WNE Excess Athletic Accident Insurance information.

In order for this plan to process the balance on an injured student-athlete’s medical claim an itemized bill

from the provider and copy of the primary insurance Explanation of Benefits (EOB) are always needed. To ensure

that claims are process in a timely manner it is important that the treating medical provider has the billing

information for WNE’s Excess Athletic Accident Insurance plan. However, if this is not done ahead of time

and a bill ensues, the following actions should be fulfilled by the student-athlete in order for the claims

company to process the claim:

1. Call the medical provider’s Billing Department.

(Telephone number found on the balance due statement)

2. Inform the Billing Department that you have an excess insurance policy.

3. Give the Billing Department the excess insurance policy information:

Claims Company: Mutual of Omaha

Mailing Address: PO Box 31156

Omaha, NE 68131

Phone Number: (800) 524 2324

Fax Number: (402) 351 4732

Group Name: WNE Athletics

4. Instruct the Department to send the following Billing to Mutual of Omaha:

a. HCFA-1500 or UB04 Form (for the date(s) of service listed on statement/bill)

b. Primary Insurance Explanation of Benefits (EOB)

5. For reimbursement on bills already paid out of pocket, forward all receipts and/or proof of

payment to Mutual of Omaha along with the above documentation.

Please note: If you have any questions regarding coverage under the Athletic Accident Insurance policy you may contact

GSH&SR at 877-345-8928 or Mutual of Omaha at 800-524-2324.