Required Information

Date of Service Provider's Name
Patient's Name Patient's ID #

   My claim was denied
           Fax a copy of your explanation of benefits or doctor's bill to us for review or Call for explanation and advice.
   My doctor has received no response from my insurance carrier on a claim that was submitted
           Call Member Services to see if the claim was received. If not, ask your doctor to resubmit the claim.
   Please get back to me on the following claims issue: