Sending A Form or Document

 

* indicates a mandatory field.
Use the drop down below to select who is to receive an attachment.
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Enter your assigned provider number.
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Telephone Number:
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Claim form ID can be found on the explanation of benefit statement.
Please enter the plan member ID

Attach form or document * (Overall maximum per submission is 4 MB): Attach a document by clicking the browse button and following the instructions.  Acceptable file types (extensions) are: bmp, doc, docx, gif, jpeg, jpg, pdf, png, tga, tif, tiff, txt, xls and xlsx.

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By submitting this form or document, I acknowledge I have written authorization to submit personal information to the Carrier/Adjudicator/Third Party Payor, and for the Carrier/Adjudicator/Third Party Payor to exchange information with other parties as required and only when the information is needed to administer and/or to confirm the accuracy of the information in the form or document.
I agree the information provided is complete and accurate, to the best of my knowledge.