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Claims
 
The following forms may be printed from your personal computer and sent to the Plan Office via the postal service. All forms are valid only when both the Member ID # and signature of the Participant are provided.



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Select from the following category to reduce your search and scroll down to locate the form you are looking for.

Patient and/or Participant Forms
Physician and/or Provider Forms

PATIENT/PARTICIPANT
Check Trace Form - Participants and Providers use this form to request the MPI Health Plan to trace a claims check or to issue a "Stop Payment" and reissue a claims check.
Change of Address - To ensure that you receive correspondence sent from the Plan, it is important that you notify the Eligibility Department immediately of any change in your mailing address.
Express Scripts/Medco By Mail - To begin using Express Scripts/Medco's home delivery pharmacy service, click on the link and print the forms. Be sure to follow the instructions on the forms. (You will need to download a free copy of Adobe® Reader® if you do not have it installed already.) Mail your original prescription(s) along with completed forms to:

Express Scripts/Medco
P.O. Box 30493
Tampa, FL 33630-3493


If you need a supply of your medication immediately, ask your doctor to write a separate prescription that you can fill at your local retail pharmacy.
Express Scripts/Medco Brochure

Express Scripts/Medco Coordination of Benefits / Direct Claim Form -- Use this form if you pay for a prescription, or co-pay from your other drug plan, and would like to be reimbursed from Express Scripts/Medco. Submit the completed form to Express Scripts/Medco at the address on the form. Claims must be submitted within 12 months from the date of fill. Failure to timely file may result in the denial of your claim. You will be reimbursed at the rate of 85% of the allowable amount, less the co-payment. Reimbursement is based on generic or lower cost brand-name products, if either is available.
MPIHP Medical Claim Form - You or your health care provider can use this form to submit claims for medical care.
OptumHealth, Behavioral Solutions, Out-of-Network Claim Form - This HCFA 1500 claim form is to be used solely when filing for reimbursement with OptumHealth Behavioral Solutions for services obtained outside of the Optum network. Submit completed forms with itemized bills to:

OptumHealth, Behavioral Solutions
Claims Department
P.O. Box 31053
Laguna Hills, CA 92654-1053

BlueCard Worldwide® International Claim Form - The BlueCard International Claim Form is to be used to submit institutional and professional claims for benefits for covered services received outside the United States, Puerto Rico, Jamaica and the U.S. Virgin Islands. It is important to have the foreign provider include all supporting medical information along with the bill. Send completed form and documentation to:

BlueCard Worldwide Service Center
P.O. Box 72017
Richmond, VA 23255-2017 USA


Medical services incurred while on a cruise ship must be submitted to the West Coast MPI Health Plan Office.
Delta Dental Claim Form - All dental claim forms, including claims for services performed outside the United States, should be sent to:

Delta Dental of California
Claims Department
P.O. Box 997330
Sacramento, CA 95899-7330

Coordination of Benefits-Spouse's Requirements Under Anthem Blue Cross - Please read this 2-page letter to determine which forms to complete.
Coordination of Benefits "Form 1" Questionnaire - Participants must complete and submit this "Form 1" in order to establish health eligibility for their spouse or same-sex domestic partner with the MPI Health Plan.
Coordination of Benefits "Form 2" Questionnaire - The spouse's/same-sex domestic partner's employer completes this "Form 2" certifying to their health insurance status.
Coordination of Benefits "Form 3" Declaration - Participants' spouses or same-sex domestic partners who are retired, unemployed, self-employed, or freelance and have no group health plan may remain covered by the MPIHP, but must fully complete, sign and submit this Coordination of Benefits Declaration and "Form 1" above.
Coordination of Benefits "Form 4" Confirmation - Participant's spouse/same-sex domestic partner must complete this confirmation of employer group health plan enrollment. Also indicates coverage provided for children under employer group health plan.

If you previously notified the MPI Health Plan of possible future enrollment in your employer's group health plan, this form must be completed and returned to the MPIHP Office upon actual enrollment in that plan.

If the MPI Health Plan determines that the spouse was eligible for health benefits through their employer but did not enroll, the MPI Health Plan will not provide any coverage for the spouse.
Third Party Liability/Workers' Compensation - Complete this form in full if you've had any sort of accident or illness which may be third party or workers' comp-related. We must have your completed form within 30 days of the injury or illness or else related claims will be denied. One form is required for each injury/illness and for each person. It is recommended that you not settle any personal injury claim without notifying the Plan Office.
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PHYSICIAN/PROVIDER
Claim Review Request - Providers requesting review of previously adjudicated claims must submit this form. The original MPI claim number must be included on this form for timely processing.
Check Trace Form - Participants and Providers use this form to request the MPI Health Plan to trace a claims check or to issue a "Stop Payment" and reissue a claims check.
Substitute Form W-9 - New providers submitting claims to the Plan Office must complete and submit W-9 information before claims can be processed. Also, a new form must be submitted if you made a change to your business name or Tax I.D. number.
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