I am a...
*
Provider
Policyholder
Authorized Representative
Name
*
Back
Next
Authorized Representative Documentation
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
I have an inquiry regarding...
*
Claim Status
Request for Explanation of Benefit
Claim shows as paid but I never received payment
Claim is not in the Portal
Portal Issue
Other
Back
Next
Tax ID
*
Back
Next
Do you have a check number?
*
Yes
No
Back
Next
Check Number
*
Back
Next
Do you have a claim number?
*
Yes
No
Back
Next
Claim Number
*
Typically a 15 digit number.
Back
Next
Member ID
*
Please enter all 11 digits of the policy (no dash).
Provider
*
Date of Service
*
/
Month
/
Day
Year
Only DOS prior to 8/31/2023 will be submittable.
Date of Service (ending date)
/
Month
/
Day
Year
Complete if applicable.
Billed Amount
*
Please enter the formatting above.
Back
Next
Question/Inquiry
*
Please describe your inquiry.
Additional Information
You are welcome to provide additional information that may be helpful in resolving your inquiry.
Attachment
Browse Files
Drag and drop files here
Choose a file
Optional
Cancel
of
Back
Next
What is the Member's date of birth?
*
-
Month
-
Day
Year
Last 4 of SSN
*
Back
Next
Method of Follow-Up
*
Email
Fax
US Mail
Back
Next
Email
*
Confirmation Email
example@example.com
Back
Next
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Would you like all future correspondence to be mailed to the address provided?
Yes
No
Back
Next
Fax Number
*
Please enter a valid fax number.
Format: (000) 000-0000.
Fax Extension
Back
Next
Would you like a confirmation email following submission of your inquiry?
*
Yes
No
Back
Next
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.
Submit
Response
Response 2
Response Supporting Documentation
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Previous Communication
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Inquiry ID
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Extension
Should be Empty: