Customer Service Question Form

To submit a question, please complete the information requested. This is a secure form.
 
* All fields required unless noted
Member Inquiry      
Identification number    
Member's first name Member's last name
Street address  
City State
ZIP  
 
Your relationship to the member Self     Spouse      Child
Other
(please define) 
Your first name
Your last name
 
Your question is for Self     Spouse      Child      Other
 
How would you like to receive response? E-mail
Your e-mail address
  Mail    
 
I have a question about Claim(s)    
  Benefits for a specific service  
  Other    

Question about a claim #1
Date of service / / Pick a Claim From Date / / Pick a Claim To Date  
  From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
 
Patient first name Patient last name
Patient date of birth / / Pick your Date of Birth    
  (mm/dd/yyyy)    
Provider name Total charge (optional)
How may we help you? of 500 characters maximum allowed
I have another claim inquiry on this patient I have a claim inquiry on a different patient

Question about a claim #2
Date of service / / Pick a Claim From Date / / Pick a Claim To Date  
  From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
 
Patient first name Patient last name
Patient date of birth / / Pick your Date of Birth    
  (mm/dd/yyyy)    
Provider name Total charge (optional)
How may we help you? of 500 characters maximum allowed
I have another claim inquiry on this patient I have a claim inquiry on a different patient

Question about a claim #3
Date of service / / Pick a Claim From Date / / Pick a Claim To Date  
  From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
 
Patient first name Patient last name
Patient date of birth / / Pick your Date of Birth    
  (mm/dd/yyyy)    
Provider name Total charge (optional)
How may we help you? of 500 characters maximum allowed
I have another claim inquiry on this patient I have a claim inquiry on a different patient

Question about a claim #4
Date of service / / Pick a Claim From Date / / Pick a Claim To Date  
  From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
 
Patient first name Patient last name
Patient date of birth / / Pick your Date of Birth    
  (mm/dd/yyyy)    
Provider name Total charge (optional)
How may we help you? of 500 characters maximum allowed
I have another claim inquiry on this patient I have a claim inquiry on a different patient

Question about a claim #5
Date of service / / Pick a Claim From Date / / Pick a Claim To Date  
  From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
 
Patient first name Patient last name
Patient date of birth / / Pick your Date of Birth    
  (mm/dd/yyyy)    
Provider name Total charge (optional)
How may we help you? of 500 characters maximum allowed
I have another claim inquiry on this patient I have a claim inquiry on a different patient

Question about a claim #6
Date of service / / Pick a Claim From Date / / Pick a Claim To Date  
  From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
 
Patient first name Patient last name
Patient date of birth / / Pick your Date of Birth    
  (mm/dd/yyyy)    
Provider name Total charge (optional)
How may we help you? of 500 characters maximum allowed
I have another claim inquiry on this patient I have a claim inquiry on a different patient

Question about a claim #7
Date of service / / Pick a Claim From Date / / Pick a Claim To Date  
  From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
 
Patient first name Patient last name
Patient date of birth / / Pick your Date of Birth    
  (mm/dd/yyyy)    
Provider name Total charge (optional)
How may we help you? of 500 characters maximum allowed
I have another claim inquiry on this patient I have a claim inquiry on a different patient

Question about a claim #8
Date of service / / Pick a Claim From Date / / Pick a Claim To Date  
  From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
 
Patient first name Patient last name
Patient date of birth / / Pick your Date of Birth    
  (mm/dd/yyyy)    
Provider name Total charge (optional)
How may we help you? of 500 characters maximum allowed
I have another claim inquiry on this patient I have a claim inquiry on a different patient

Question about a claim #9
Date of service / / Pick a Claim From Date / / Pick a Claim To Date  
  From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
 
Patient first name Patient last name
Patient date of birth / / Pick your Date of Birth    
  (mm/dd/yyyy)    
Provider name Total charge (optional)
How may we help you? of 500 characters maximum allowed
I have another claim inquiry on this patient I have a claim inquiry on a different patient

Question about a claim #10
Date of service / / Pick a Claim From Date / / Pick a Claim To Date  
  From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
 
Patient first name Patient last name
Patient date of birth / / Pick your Date of Birth    
  (mm/dd/yyyy)    
Provider name Total charge (optional)
How may we help you? of 500 characters maximum allowed
[Up to 10 claim questions may be added at one time]

Question about benefits for a specific service
Estimated date of service / / Pick Date of Service    
  (mm/dd/yyyy)    
Patient first name Patient last name
Patient date of birth / / Pick your Birth Date  
  (mm/dd/yyyy)  
Provider name  
Type of service(i.e. office visit, lab work) of 500 characters maximum allowed
Where service to be performed (i.e. hospital, doctor's office, lab)
Why are you having this service and what information would you like us to provide you with?
  of 500 characters maximum allowed
 

Other      
Patient first name Patient last name
Patient date of birth / / Pick your Date of Birth
(mm/dd/yyyy)
   
How may we help you? of 500 characters maximum allowed
       
Thank You. We will respond within 7 calendar days.