Date:
Billing Provider:
Billing Address:
TIN:
Contact Person:
Phone:
Fax:
Patient:
DOB:
Member:
Member Id:
Physician:
Phone:

NOTE: These benefits are applicable only if the patient is an eligible enrolled member of a HealthChoice plan. All benefits are subject to the deductible, coinsurance and policy provisions. Please verify benefits and eligibility by calling the medical claims administrator toll-free at 800-323-4314.

ICD code and summary of care:

HCPC code(s) must include descriptions for all miscellaneous codes:

Rental:           Yes      No

Purchase:      Yes      No

 

NOTE: Any changes or additional services require updated information.

 

Date(s) of Service being requested:
Upload Document:

NOTE: If the date of service has already occurred, it must be included to complete review.

** All information is required for review. Information provided is private and confidential. **

NOTE: These benefits are applicable only if the patient is an eligible enrolled member of a HealthChoice plan. All benefits are subject to the deductible, coinsurance and policy provisions. Please verify benefits and eligibility by calling the medical claims administrator toll-free at 800-323-4314.

MEDICARE PATIENTS: If HealthChoice provides coverage that is supplemental to Medicare, all requested services must be approved by Medicare. The Medicare EOB should be filed for claims processing.