Itemized Bill Submission

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• * Required Field

  Enter Claim Information

• Claim Number:
• We're unable to prepopulate the below information using ID you entered.
• Member ID Number
  (3-digit prefix followed by remaining digits):*
• • i
  • i
  • i
• Patient First Name: *
• Patient Middle Initial:
• Patient Last Name: *
• Date of Birth: *
  Must be valid date.
• Admission Date:

• Enter Contact Information

• Contact First Name: *
• Contact Last Name: *
• Contact Email Address:
• Contact Phone Number: *
  Enter a 10 digit phone number.
  Ext.
• Contact Fax Number: *
  Enter a 10 digit phone number.

•  

  Enter Facility Information

• Provider ID OR NPI: *
• Facility Name: *
• Facility Address: *
• Facility City: *
• Facility State: *
• Facility Zip: *

You must attach the itemized bill: *

Please Note: Maximum attachment size is 5 MB.

Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif) *

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

• Checking this box will send a copy of your form to the email address provided.