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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:	E-mail Phone Mail
Questions/Comments:*