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Claim Inquiry (Members)

To inquire about the priced status of a medical claim, complete and submit the form below or call 1-800-601-9208.   The Claim Inquiry Form should be used for medical claims pricing inquiries only.   A response will be submitted within 2 business days.   To inquire about the payment status of a medical claim, call your Administrator’s claim inquiry phone number on your ID card.

Fields marked with an asterisk (*) are required.

Sender Information
*Name:  
*Date of Birth:
*Email Address:
*Address:  
*City:  
*State:
*Zip:
*Home Phone: () - -
Work Phone: () - -

Member / Patient Information
*Member ID Number:  
*Service Provider Name:  
MMO Claim Number:
*Patient Name:  
*Date of Service:
*Dollar Amount of Claim: $
Employer:  
Respond Via:
Questions/Comments:*