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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{ "rules": { "requestorEmail": { "email": 1 } }, "messages": { "requestorEmail": { "email": "Your email address must be in the format of name@domain.com" } } }

Requestor Information

Requestor Information

Member Information

Member #1

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." } } }

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)
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