STUDENT-ATHLETE MEDICAL BILLING POLICY
The College of the Holy Cross provides a medical insurance program for its student-athletes. THIS POLICY,
HOWEVER, IS SECONDARY TO, OR IN EXCESS OF, PERSONAL FAMILY MEDICAL INSURANCE COVERAGE, and
covers only injuries/illnesses/accidents resulting from the direct participation in the intercollegiate athletics
program during the dates of the primary competitive season and designated off-seasons.
Student-Athlete’s parent(s)/guardian(s) are encouraged to contact their insurance company prior to their
son/daughter’s arrival at Holy Cross to ensure that medical coverage is extended to “out of network” coverage
during their duration of their time at Holy Cross. If your insurance company will not allow out of network coverage,
you must purchase the College’s student health insurance policy.
It is the responsibility of the Student-Athlete and his/her parent(s) / guardian(s) to understand the conditions that
apply to their personal health insurance policy and comply with any requests for information, etc. from the primary
insurance company.
HMOs
If a student-athlete's primary insurance is an HMO, the College of the Holy Cross Sports Medicine Department
strongly encourages the student-athlete and/or his/her parent(s) / guardian(s) to change the primary care
physician (PCP) to a College of the Holy Cross Team Physician or local physician. This will allow the student-
athlete to have a network of physicians in the Worcester, MA area as well as better access to care. The College of
the Holy Cross Sports Medicine staff can assist in this process.
INSURANCE POLICY CHANGES:
All Student-Athletes must provide a copy of their insurance card to the Sports Medicine Department to be retained
in their medical file prior to participation of their respective sport. In the event that the Student-Athlete’s insurance
policy changes, the College of the Holy Cross staff must receive any changes to a health insurance policy as soon as
they occur. If proper notification is not received, the College of the Holy Cross Department of Athletics may not be
responsible for any delays in payment.
EXCLUSIONS AND LIMITATIONS:
The College of the Holy Cross Athletic Department is not responsible for bills incurred by a Student-Athlete as a
result of injury/illness unrelated to intercollegiate athletic participation.
The College of the Holy Cross Athletic Department is not financially responsible for expenses incurred by a
Student-Athlete for medical services obtained without referral or authorization by the Team Physician or a
member of the College of the Holy Cross Sports Medicine Staff.
The College of the Holy Cross Athletic Department is not responsible for payment of medical expenses incurred
while the Student-Athlete is uninsured or has allowed their personal policy to lapse/expire/term.
The College of the Holy Cross Athletic Department is not responsible for payment of medical expenses of
injuries/illnesses that are recurrences of injuries/illnesses which were sustained before participation in the
intercollegiate sports program at the College of the Holy Cross.
The College of the Holy Cross Athletic Department is not responsible for expenses for athletic injuries incurred
after completion of the Student-Athlete's intercollegiate athletic eligibility.
THE PROCEDURE:
1. If a student-athlete is referred to a doctor’s office or the hospital for an athletically incurred injury, a claim form
will be submitted by the Athletic Trainer to A-G.
2. The student-athlete must present their primary insurance card along with the athletic issued A-G Insurance Card
when they arrive at their appointment or the hospital.
• If you don’t initially present A-G as your secondary insurance to the provider, you and/or your insurance
policy holder, are responsible for calling the provider to resolve your bills. If this step is not complete, you
may incur penalty charges and/or collections.
3. Claims will be processed through your primary insurance first. Any excess amount not covered by the primary
will be submitted to A-G.
4. If itemized insurance bills, including Explanation of Benefits (EOB), are received from your primary carrier,
please mail/email them to the claims administrator below.
A-G Administrators – Claims Department
PO Box 21013
Eagan, MN 55121
claims@agadm.com
5. Questions regarding benefits, medical bill status, etc. should be directed to A-G Administrators – Claims Department
(610) 933-0800.
I have read and agree to comply with the Student-Athlete Medical Billing Policy as put forth by the College of the Holy
Cross Athletic Department. My signature below verifies that I have read, understand, and have been provided with a
copy of this policy and its procedures.
SIGNATURE OF POLICY HOLDER: DATE:
PRINT NAMEOF STUDENT-ATHLETE: SPORT:
STUDENT-ATHLETE INSURANCE INFORMATION
Student-Athlete: Date of Birth:
Anticipated Year of Graduation: Student ID#: Sport(s):
Home Address: City: State:_ Zip:
Home Phone #: Student Cell Phone #:
Emergency Contact #1 Name: Relationship to Athlete:
Home Phone #: Cell Phone #:
Emergency Contact #2 Name: Relationship to Athlete:
Home Phone #: Cell Phone #:
Policy Holder’s Name: Date of Birth:
Policy Holder’s Home Phone #: Policy Holder’s Cell Phone #:
Policy Holder’s Employer:
Employer’s Address: City: State: Zip:
Insurance Company: Customer Service Phone #:
Insurance Address: City: State: _ Zip:
Group Number: ID/Member Number: Other Number: _Insurance Type: HMO
PPO POS UNRESTRICTED If policy is an HMO, is guest coverage available? YES NO
Primary Care Physician (PCP): PCP Phone #:
Does your policy cover athletic related injuries?
YES
NO Is a referral required from your PCP to see a specialist?
YES
NO
Policy Holder’s Name: Date of Birth:
Policy Holder’s Home Phone #: Policy Holder’s Cell Phone #:
Policy Holder’s Employer:
Employer’s Address: City: State: Zip:
Insurance Company: Customer Service Phone #:
Insurance Address: City: State:_ Zip:
Group Number: ID/Member Number: Other Number:
I hereby certify that the answers provided are true, complete and correct to the best of my knowledge. I understand that my
son/daughter must carry an insurance policy that will remain valid during their duration as a student-athlete. I understand that it is
my responsibility to update the Holy Cross Sports Medicine Department of any changes or updates to the student-athlete’s insurance
information.
SIGNATURE OF POLICY HOLDER: DATE:
PRIMARY INSURANCE INFORMATION
Please fill in the following information with the student-athlete’s primary insurance information.
PLEASE PRINT ALL INFORMATION REQUESTED ON THIS FORM LEGIBLY
All information will be kept confidential and used solely for the purpose of providing appropriate medical care for the student–athlete.
SECONDARY INSURANCE INFORMATION
(IF APPLICABLE)
Please fill in the following information with the student-athlete’s secondary insurance information.
