Hospital ICU Insurance Claim Filing Instructions

Does your claim meet the definition for Hospital Intensive Care (ICU)?

Definition of Hospital Intensive Care (ICU):

Those special intensive care areas of a hospital which at the time of your admission to the hospital are also separate and apart from the surgical recovery room and from the rooms, beds, and wards customarily used for patient confinement.

The term "intensive care unit" does NOT include lesser treatment units such as:

  • Progressive or intermediate care units,
  • Private monitored rooms,
  • Isolation units, observation or
  • Telemetry units

These units are classified on the UB-04 in the ‘Revenue Code ‘column and are not covered. Revenue Codes for lesser treatment units include but are not limited to the following: 0204, 0205, 0206, 0209, and 0214.
Please click on the sample to see where these codes are located on the UB-04 form: UB04 Sample - Revenue Codes

Submitting a Hospital Intensive Care Claim on Policies Less than 2 Years Old

  1. Complete the Claimant Statement, HIPAA Release, and Medical Provider History. Printable claim forms can be found below:

    Claimant Statement
    HIPPA Release
    Medical Provider History

    Please also include a copy of the CMS 1500 or UB-04 form (only associated with hospital stays) and any itemized medical bills you would like to have considered for payment. Examples can be found below:

    CMS1500 Example
    UB04 Example
    Itemized Medical Billing Example
    Private Nursing and Transportation Statement

  2. If disability is being claimed, in addition to the documentation above, please have your employer fill out Part A and your physician fill out Part B on the Disability Claim Form. A printable form can be found here - Disability Claim Form.

  3. Please mail the completed documentation to the following address:

    Liberty National Life Insurance Company
    Attn: Policy Benefits
    P.O. Box 8080
    McKinney, TX 75070


Please note: We will examine each covered person(s) for our consideration of each person(s) pending claim. This will be done at the company's expense. If at any time during the review of your claim we find that we need additional information, we will notify you in writing.

Submitting a Hospital Intensive Care Claim on Policies More than 2 Years Old

  1. Complete the Claimant Statement. Printable Claimant Statement can be found here - Claimant Statement

    Please also include a copy of the CMS 1500 or UB-04 form (only associated with hospital stays) and any itemized medical bills you would like to have considered for payment. Examples can be found below:

    CMS1500 Example
    UB04 Example
    Itemized Medical Billing Example
    Private Nursing and Transportation Statement

  2. If disability is being claimed, in addition to the documentation above, please have your employer fill out Part A and your physician fill out Part B on the Disability Claim Form. A printable form can be found here - Disability Claim Form.

  3. Please mail the completed documentation to the following address:

    Liberty National Life Insurance Company
    Attn: Policy Benefits
    P.O. Box 8080
    McKinney, TX 75070


If you have questions or need assistance with filing your claim, please contact our Customer Service Department at:

Phone: (800) 333-0637 or (205) 325-4979
Customer Service email
Hours of Operation:
7:30 a.m. to 5 p.m. Central
Monday through Friday