Claims Inquiry Form

For faster service, please fill out as much of the following information as you can.

* = Required Field

Name:*
 Phone:
Fax:
 E-Mail:
Group Name:
 Group Number:
Date of Service:
 Provider's Number:
Patient's Name:
 Patient's ID#:
 My claim was denied
      Fax a copy of your explanation of benefits or doctor's bill to us for review or Call for explanation and advice.
 My doctor has received no response on a claim that was submitted
      Call Member Services to see if the claim was received. If not, ask your doctor to resubmit the claim.
 Please get back to me on the following claims issue

Miscellaneous Questions or Comments