How to submit a Student Assurance Insurance Claim

Non Student-athletes

1. Obtain a Student Assurance Claim form by going to http://www.sas-mn.com/claimform_download.html, then click on the claim form tab OR you may contact Donna Gerlach, RN, at (605) 995-2957, or stop at her office in Prather Hall.
2. Complete the top information section of the claim form and questions one through 10. Be sure to address all questions within the numbered area. Sign and date the bottom of the form.
3. After completing the claim form, attach a copy of the coded bill(s) from your medical provider(s) for services rendered. If submitting pharmaceutical bill(s), include a copy of the prescription receipt attached to your medication with name of medication, directions for use and cost, along with a copy of the cash register receipt.
4. You may self submit this claim to Student Assurance Services, INC., P.O. Box 196, Stillwater, MN 55082-0196, or you may turn in the completed claim form along with all of the required information to Donna Gerlach, 1200 West University, Box 906, Mitchell, SD 57301.
5. If you have questions, contact Donna Gerlach, RN, at dogerlac@dwu.edu or call (605) 995-2957.

Athletes

1. After your primary insurance has been billed and processed, the remaining out-of-pocket expenses that you incurred from your athletic injury may be submitted to your secondary insurance provided through Student Assurance Services.
2. Obtain a Student Assurance Claim form by going to http://www.sas-mn.com/claimform_download.html and click on the claim form tab OR you may contact Jarod Guthmiller, head athletic trainer at (605) 995-2144, or go to his office located in the Christian Family Recreation/Wellness Center.
3. Complete the top informational section of the claim form and questions one through 10 of the Student Assurance Claim form. Be sure to address all questions within the numbered area. Sign and date the bottom of the form.
4. Ask your medical provider if their facility will bill the secondary Student Assurance. If the facility does bill secondary insurance, let them proceed with the claim. If they do not bill secondary insurance, return all of the following required information to Jarod Guthmiller, 1200 West University Ave., Box 912, Mitchell, SD 57301.
   • The completed Student Assurance Claim form, signed and dated
   • A copy of your private insurance’s explanation of benefits (EOB)
   • A coded copy of the medical bill(s) or HICFA form(s) from all of your medical providers
   • Prescription receipts if applicable
5. In house secondary insurance through Student Assurance Services will not be billable if the athlete’s primary insurance is not in effect at the time of the injury.