Policy Number
GLM N18157081
Call:
+1-800-303-8120
(option 5)
Email:
claimhelp@mycisi.com
This plan is provided by Cultural Insurance Services International
and underwritten by Ace American Insurance Company,
a member of the Chubb Group of Companies
Coverage and/or Claim Questions?
Contact CISI by:
Phone: 1-203-399-5130
Email: claimhelp@mycisi.com
For Emergencies (24/7/365) – Contact AXA Assistance
(Inpatient or Emergency Care)
Call AXA Assistance at (855) 327-1411 (in U.S) or
+001 (312) 935-1703 (call collect from outside of the U.S).
Email: medassist-usa@axa-assistance.us
You can locate your ID card and policy brochure by creating an account by clicking on “Login to myCISI”. You can find the login button on the top of this page or by clicking here.
For the full coverage, please refer to your policy brochure which was sent to you by email or it can be found within your participant portal. Your plan covers things like the flu, stomach bug, appendicitis, COVID, pink eye and much more.
You will need to refer to your policy brochure, though a few common exclusions would be, vaccinations, wellness care/immunization, along with vision such as eye glasses or contact lenses and dental cleaning.
The following activities are not covered under the BASIC plan: injury sustained while taking part in mountaineering where ropes or guides are normally used; hang gliding; parachuting; bungee jumping; racing by horse, motor vehicle or motorcycle; parasailing; scuba diving, jet, or water skiing; sky diving; amateur racing; piloting an aircraft; spelunking; whitewater rafting; snowboarding; snowmobiling; zip line and martial arts performed under the supervision of an in structure (i.e., boxing, taekwondo, karate).
The above activities are only covered under the UPGRADED plan.
For illnesses or injuries that are not life threatening, please utilize our provider search tool to find an Aetna Urgent Care, Walk in Clinic or Physician’s office near you. This Policy utilizes the Aetna Preferred Provider hospital and Doctor network for the purpose of delivering quality health care at a preferred fee. You are not required to use the PPO network but you may incur expenses that are not covered under your policy by utilizing an out of network provider. Please contact CISI for additional information. You are also welcome to use Retail Clinics at CVS, Walgreens, Walmart, Target or Kroger stores.
If you visit a medical provider (doctor, hospital, clinic, etc) that is not in the Aetna network, you may be required to pay for these services yourself. If so, please specifically request an itemized bill from the medical provider to submit to your insurance. The itemized bill includes diagnosis and procedure codes necessary to process a claim. This type of bill is standard in medical billing in the United States. Once you have this, a claim form (PDF) can be completed and submitted to CISI.
If you are being treated for an illness or injury which would otherwise be covered under your CISI policy, your physician prescribed medication would also be covered. All prescription medications must be paid by you to the pharmacy at the point of purchase. You are encouraged to download the Prescription Rx Card. A claim for reimbursement can be made by submitting the prescription receipt and a completed claim form (PDF). The prescription receipt is normally stapled to the outside of the pharmacy bag and includes your name, your physician’s name, the name of the medication, the dosage and the amount charged. Cash register receipts will not be considered for reimbursement. Once you have this, a claim form can be completed and submitted to CISI.
A claim form (PDF) should be completed. Please be sure to include a brief description of the accident or illness that treatment was received for. The claim form will need to be submitted with any itemized bills that you have.
Instructions:
Complete and sign the medical claim form, indicating whether the Doctor/Hospital has been paid.
Attach itemized bills for all amounts being claimed. *We recommend that you either make photocopies of the originals for yourself, or keep the originals and submit the photocopies to CISI in case anything gets lost in the mail.
When reimbursement of an expense is approved, it will be made to the provider of the service unless the bill is noted as having been paid by you.
Payment will be mailed in U.S. dollars unless otherwise requested.
If the payment is to you, it will be mailed to your U.S. address unless otherwise requested.
If you receive a bill that states no insurance on file or self-pay, please contact the providers office billing department right away. This means they are missing our insurance information. Without this, CISI will not receive the bill. Due to privacy laws, the guardian, student or natural parents will need to call and provide the details from the CISI insurance card. The provider will ask for the member ID, group number and billing address. All this information is on the CISI/Aetna ID card.
Claim forms (PDF) are requested when additional information on an illness or injury is needed. Please complete the form detailing as much information as you can about your condition. Some information we could be looking for : If an illness: When did you first notice symptoms? What were the symptoms? Where you treated for this condition previously? If so, when? If an injury: Where were you when the injury happened? What were you doing? How did the injury occur?
You may have submitted a claim that did not include the diagnosis and procedure coding needed to process your claim. First, check your original submission. Did you submit a receipt or a statement from the medical provider? This is generally what is provided to patients but additional information is needed for insurance processing.
If you are looking for CISI to pay your claim to the medical provider
Contact the medical provider that has billed you and ensure that they have your insurance information. At the time you received our letter, we would have sent the same letter to the medical provider requesting the same bill. However, if you did not provide that medical provider with your insurance information, they may be unwilling or unable to send CISI the itemized bill due to privacy laws. You will need to submit your insurance information to the medical provider (there are usually spaces on the back of your statement from the facility with spaces to complete this information) and send it back to the provider. They also may be able to take this information from you over the phone. This way, they can send CISI what is needed directly.
If you are looking for reimbursement from CISI for medical services you have paid
You likely only submitted a receipt of payment to CISI. You can contact the medical provider whom you paid and ask for an itemized bill to submit to your insurance company. This type of billing is standard in the United States. The provider can send this bill to you and then you can resubmit a claim to CISI or the provider is welcome to send this directly to CISI.
Schedule of Benefits | |
Benefits | Limits |
Medical Expenses Limits: | |
Lifetime/Annual Maximum | Unlimited |
Per Accident or Sickness | $250,000 |
Per Occurrence Deductibles: | |
Emergency Room Deductible (waived if admitted) | $250 |
Call-A-Doc | $0 |
Physician/Outpatient/Dr. Visit | $100 |
Urgent Care | $50 |
Walk in Clinic | $25 |
MRI/CAT Scan | $0 |
Rx Copay | $0 |
Pre-Existing Conditions-12 Month Look Back; thereafter up to policy max | Up to $500 |
Coinsurance Percentage (%) | 100% Coinsurance |
Prescription Drugs (inpatient/outpatient) | Inpatient: 100% of Covered Expenses Outpatient: 100% of Covered Expenses |
Mental Health | Inpatient up to 30 days/Outpatient 30 visits |
Pregnancy (conception must occur while covered under this plan) | Treated as any other illness |
Physiotherapy | Covered |
Chiropractic Care & Therapeutic Services | Up to $500 max, $50 per visit |
Emergency Reunion | $15,000 (hospitalized 3 days) |
Home Country (Incidental Trips) | $1,000 |
Trip Delay (applies mid trip as well) 24-hour time | Up $1,500/daily limit $100 |
Political Evacuation | $10,000 |
Dental Injury Only | Up to policy max |
Palliative Dental | $1,000max/$200 per tooth |
24/7 Assistant Services & In-house Crisis Team | Included |
Medical Evacuation | $50,000 |
Repatriation of Remains | $25,000 |
Accidental Death & Dismemberment | $15,000 ($1M aggregate limit) |
Schedule of Benefits | |
Benefits | Limits |
Medical Expenses Limits: | |
Lifetime/Annual Maximum | Unlimited |
Per Accident or Sickness | $2,000,000 |
Per Occurrence Deductibles: | |
Emergency Room (waived if admitted) | $250 |
Call-A-Doc | $0 |
Physician/Outpatient/Dr. Visit | $50 |
Urgent Care | $50 |
Walk in Clinic | $25 |
MRI/CAT Scan | $0 |
Rx Copay | $0 |
Pre-Existing Conditions-12 Month Look Back; thereafter up to policy max | Up to $500 |
Coinsurance Percentage (%) | 100% Coinsurance |
Prescription Drugs (inpatient/outpatient) | Inpatient: 100% of Covered Expenses Outpatient: 100% of Covered Expenses |
Mental Health | Inpatient up to 30 days/Outpatient 30 visits |
Pregnancy (conception must occur while covered under this plan) | Treated as any other illness |
Emergency Reunion | $15,000 (hospitalized 3 days) |
Physiotherapy | Covered |
Chiropractic Care & Therapeutic Services | Up to $500 max, $50 per visit |
Home Country (Incidental Trips) | $1,000 |
Trip Delay (applies mid trip as well) 24-hour time | Up $1,500/daily limit $100 |
Political Evacuation | $10,000 |
Dental Injury Only | Up to policy max |
Palliative Dental | $1,000max/$200 per tooth |
24/7 Assistant Services & In-house Crisis Team | Included |
Medical Evacuation | $50,000 |
Repatriation of Remains | $25,000 |
Accidental Death & Dismemberment | $15,000 ($1M aggregate limit) |
Trip Interruption | $1,000 |
Personal Liability | |
Personal Liability Limit | $2,000,000 |
Liability deductible | $100 |
Medical Payments to Others | $25,000 | Additional Living Expenses | $10,000 |
Payment of Homeowners Deductible | $1,000 |
Personal Property | $1,500 |
You are now being directed to Travel Insured International. On this page, you will be able to review a quote for Trip Cancellation for Any Reason and Trip Interruption for Any Reason. Please keep in mind this plan is completely separate from the CISI AIFS Abroad Insurance Coverage. This plan can be purchased with a major credit card.
Click here to proceed: Trip Cancellation & Interruption Protection for Academic Travel (culturalinsurance.com)
Salvator Mundi International
Viale Mura Gianicolensi 67
00152 Roma
Tel: +39 06 588961
(Private Hospital)
Aventino Medical Group
Via Sant’Alberto Magno, 5, apt. 3,
00153 Rome, Italy
Tel: +39 06 5728-8349 or 06 578-0738
(Private Clinic)
*You do not need to contact TeamAssist before visiting this provider. Your ID Card is sufficient.
Mater Dei
Via Bertoloni, 34
Tel: +39-068-22-01
(Private Hospital)
EuroSanita (Villa Stuart)
Via Trionfala, 5952
00136 Roma
(Private Clinic)
*You do not need to contact TeamAssist before visiting this provider. Your ID Card is sufficient.
Casi di Cura Santo Volta Hospital
Piazza del Tempio di Diana, 13 Roma
(Private Hospital)
*Student should contact Team Assist before admission.
Paideia
Via Vincenzo Tiberio, 46
Tel: +39-063-309-41
(Private Clinic)
Valle Giulia
Via de Notaris, 2/8
Tel: +39-063-247-91
(Private Clinic)
Dr. Julia Chabrera
Av. Reina Mercedes 29, Bajo, Ext. D.
41012 Sevilla
Tel: +34-954-61-26-40
clinicachabrera@gmail.com
Clinica Fatima
C/Fglorieta de Mexico No. 1
41012 Sevilla
Tel: +34-954-613-300
(General Practice Clinic)
Usp Clinica Sagrado Corazon
C/Rafael Salgado No. 3
41013 Sevilla
Tel: +34-954-937-676
(Multi specialty clinic)
Policlinica los Remedios
c/ Fernando IV 24, 41011
Seville, Spain
Tel: 34 954 279 786
esther.policlinica@hotmail.es
(General Practice Clinic)
*You do not need to contact TeamAssist before visiting this provider. Your ID Card is sufficient.
Centro Medico Nervion
Av. San Francisco Javier No. 18
41000 Sevilla
Tel: +34-954-659-955
(General Practice Clinic)
American Hospital of Paris
63 Boulevard Victor Hugo 92200 Neuilly-sur-Seine, France
Tel: 01 46 41 25 25
(Private Hostpital)
Clinique Ambroise Pare
7 Boulevard Victor Hugo 92200 Neuilly-sur-Seine
Tel: 08 26 20 03 00
(Private Clinic)
Centre Medical Europe
44 rue d’Amsterdam 75009
Tel: 01.42.81.93.33
(Private Clinic)
International Medical Center of Paris
29 av. General Leclerc 75014 Paris
Tel: +33(0)143950055
Email: j.duplessisnelson@gmail.com
(Private Clinic)
Dr. Anne Valerie Meyers
10, Rue Royale – Dorrway C, 4th Floor – 75008 Paris
Phone: +33 (0)1 42 66 47 82
Email: avm@prontomail.com
*You do not need to contact TeamAssist before visiting this provider. Your ID Card is sufficient.
(General Practicioner)
Dr. Nancy Salzman
1 avenue de Lowendal – 75007 Paris – France
Phone: +33 (0)1 45 63 18 43
Email: drsalzman@noos.fr
(General Practitioner & Gynecology)
Justine Du Plessis Nelson
11, Rue Bosio – 75016 Paris – France
Tel: +33 (0)1.6.17.92.62. 50
Email: j.duplessisnelson@gmail.com
*You do not need to contact TeamAssist before visiting this provider. Your ID Card is sufficient.
(Mental Health / Psychologist)
Dr. Suzanne Black
+33 (0)6 3206 5806,
Email: drsuzablack@gmail.com (Appointment location will depdend upon treatment needs)
*You do not need to contact TeamAssist before visiting this provider. Your ID Card is sufficient.
(Mental Health / Psychologist)
Sharon Korman, Psychotherapy
91 Rue du Theatre – 75015 Paris
Tel: +33 (0)6 50 02 30 66, korman.lmft@free.fr
*You do not need to contact TeamAssist before visiting this provider. Your ID Card is sufficient.
(Mental Health / Psychotherapy)
Marie Rose Richardson
66 Rue de Lisbonne 75008 Paris
*You do not need to contact TeamAssist before visiting this provider. Your ID Card is sufficient.
(Mental Health)
You are now being directed to Travel Insured International. On this page you will be able to review a quote for Trip Cancellation for Any Reason and Trip Interruption for Any Reason. Please keep in mind this plan is completely separate from the CISI Boston College Travel Abroad Insurance Coverage. This plan can be purchased with a major credit card.
Click here to proceed: Trip Cancellation & Interruption Protection for Academic Travel (culturalinsurance.com)