Inquiry Form 3.0

Authorized Representative Documentation*

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I have an inquiry regarding...*

Claim StatusAppeal StatusRequest for Explanation of Benefit/PaymentClaim shows as paid but I never received paymentOther

Tax ID#*

Do you have a check number?*

YesNo

Check Number*

Do you have a claim number?*

YesNo

Claim Number*
Enter a 15 digit claim number.

Member ID#*
Please match the formatting above.
Provider*
Date of Service*

MonthDayYear
Only DOS prior to 8/31/2023 will be submittable.
Date of Service (ending date)

MonthDayYear
Complete if applicable.
Billed Amount*
Please enter the formatting above.

Question/Inquiry*
Please describe your inquiry.
Additional Information
You are welcome to provide additional information that may be helpful in resolving your inquiry.
Attachment

Optional (accepted formats: pdf, doc, docx)
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What is the Member's date of birth?*

MonthDayYear
Last 4 of SSN*

Method of Follow-Up*

EmailUS Mail

Email*

Confirmation Emailexample@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Would you like all future correspondence to be mailed to the address provided?

YesNo

Would you like a confirmation email following submission of your inquiry?*

YesNo

Call Reference ID
If you have a call reference ID retrieved from an agent and it is regarding the inquiry above, inputting it may streamline processing.
Response
Response Supporting Documentation

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Association Name
Association Address Ln 1
Association Address Ln 2
Should be Empty: