Insurance Coverage Request Form

This form is utilized to add, terminate or change multiple insurance policy information for a beneficiary. Please add all beneficiary information, as well as all policy holder information. Multiple beneficiaries can be added to this request, as long as the changes are identical for the beneficiaries included on this form. Please complete as much information as possible to ensure timely completion. All required information is needed in order for this form to be submitted. Submitted forms that are missing information may not be reviewed.

You will receive a confirmation message and confirmation number indicating that your information has been received. Please allow up to 10 business days for information to be verified and updated in the system. If you include your e-mail address under the Requestor Information section you will receive an e-mail along with the confirmation number and the status of your request, once it has been reviewed and completed.

To report this information by phone, please contact Provider Support at 1-800-292-2550.

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Requestor Information

First Name

Last Name

Organization Type

Organization Name

Phone Number

Please provide a requestor phone number including area code. Format: ###-###-#### x####, extension is optional.

Email Address

Member Information

Member #1

First Name

Last Name

Date of Birth

Please provide a beneficiary/client date of birth. Format: MM-DD-YYYY

MiHealth ID

Case Number

Policy Information

Policy #1

{ "groups": { "coverage-flags[0]": "policies[0].dentalFlag policies[0].ltcFlag policies[0].medicalFlag policies[0].medicareFlag policies[0].pharmacyFlag policies[0].psychFlag policies[0].visionFlag" }, "rules": { "policies[0].policyRequestType": { "required": 1 }, "policies[0].dentalFlag": { "require_from_check_groups": [1, "coverage-flags[0]"] }, "policies[0].ltcFlag": { "require_from_check_groups": [1, "coverage-flags[0]"] }, "policies[0].medicalFlag": { "require_from_check_groups": [1, "coverage-flags[0]"] }, "policies[0].medicareFlag": { "require_from_check_groups": [1, "coverage-flags[0]"] }, "policies[0].pharmacyFlag": { "require_from_check_groups": [1, "coverage-flags[0]"] }, "policies[0].psychFlag": { "require_from_check_groups": [1, "coverage-flags[0]"] }, "policies[0].visionFlag": { "require_from_check_groups": [1, "coverage-flags[0]"] } }, "messages": { "policies[0].dentalFlag": { "require_from_check_groups": "Please check at least 1 policy type." }, "policies[0].ltcFlag": { "require_from_check_groups": "Please check at least 1 policy type." }, "policies[0].medicalFlag": { "require_from_check_groups": "Please check at least 1 policy type." }, "policies[0].medicareFlag": { "require_from_check_groups": "Please check at least 1 policy type." }, "policies[0].pharmacyFlag": { "require_from_check_groups": "Please check at least 1 policy type." }, "policies[0].psychFlag": { "require_from_check_groups": "Please check at least 1 policy type." }, "policies[0].visionFlag": { "require_from_check_groups": "Please check at least 1 policy type." } } }

Request Type

Check all policy types that apply

Medical

Pharmacy

Dental

Vision

Mental Health

Long-Term Care

MEDICARE

Insurance Company Name

Policy Number

Policy Number is an important input field. Please provide a policy number/contract number, if available, to enable validation of this change.

Group Number

First Name

First Name is an important input field. Please provide a policy holder first name, if available, to enable validation of this change.

Last Name

Last Name is an important input field. Please provide a policy holder last name, if available, to enable validation of this change.

Date of Birth

Date of Birth is an important input field. Please provide a policy holder date of birth, format: MM-DD-YYYY, if available, to enable validation of this change.

Social Security Number

Employer Name

Attach Document(s)

Please attach necessary documents relating to this particular request only. Unrelated attachments will not be reviewed. Relevant documents could include insurance card copies, letters on insurance company letterhead, and/or court documents. No documentation is required, 5 maximum.

Attach Document(s)

Select 'Browse' to pick a file from your computer to upload,
or drag files here to upload them.
Accepted file types: .pdf, .png, .doc, .docx, .tiff, .tif, .jpeg, .jpg, .bmp

Additional Information

Comments

This request is in response to a Claim Void Letter