Inquiry Form

I am a...*

ProviderPolicyholderAuthorized Representative
Name*

Authorized Representative Documentation*

Cancelof

I have an inquiry regarding...*

Claim StatusRequest for Explanation of BenefitClaim shows as paid but I never received paymentClaim is not in the PortalPortal IssueOther

Tax ID*

Do you have a check number?*

YesNo

Check Number*

Do you have a claim number?*

YesNo

Claim Number*
Typically a 15 digit number.

Member ID*
Please enter all 11 digits of the policy (no dash).
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
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What is the Member's date of birth?*

MonthDayYear
Last 4 of SSN*

Method of Follow-Up*

EmailFaxUS 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

Fax Number*
Please enter a valid fax number.
Fax Extension

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 2
Response Supporting Documentation

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Previous Communication

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Inquiry ID
Phone Number
Please enter a valid phone number.
Extension
Should be Empty: