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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:	<--Name Required!
*Date of Birth:	<--Birthdate Required! <--Invalid Date!
*Email Address:	<--Email Required! <--Invalid Email!
*Address:	<--Address Required!
*City:	<--City Required!
*State:
*Zip:	<--Zipcode Required! <--Invalid Zipcode!
*Home Phone:	() - - <--Phone Number Area Code Required! <--Phone Number Exchange Required! <--Phone Number Line Required! <--Invalid Phone Number Area Code! <--Invalid Phone Number Exchange! <--Invalid Phone Number Line!
Work Phone:	() - - <--Work Number Area Code Required! <--Work Number Exchange Required! <--Work Number Line Required! <--Invalid Work Number Area Code! <--Invalid Work Number Exchange! <--Invalid Work Number Line!

Member / Patient Information
*Member ID Number:	<--ID Required!
*Service Provider Name:	<--Provider Required!
MMO Claim Number:	<--Claim Number Required!
*Patient Name:	<--Patient Name Required!
*Date of Service:	<--Date of Service Required! <--Invalid Date!
*Dollar Amount of Claim:	$ <--Dollar Amount Required! <--Invalid Amount!
Employer:	<--Employer Required!
Respond Via:	E-mail Phone Mail
Questions/Comments:*	<--Comments Required!