How to file a claim
Click on these links for plans guidelines about filing your claim.
PCIP Appeal Form
To request PCIP benefits:
- File your claim.
Providers will file claims as indicated on the ID card, using a HCFA 1500 health insurance claim form. Claims from other providers may be submitted by either you or by the provider. Claims submitted by providers should be filed on HCFA 1500 claim forms. Your facility will file on the UB-04 form. If you submit a claim yourself, you do not need a claim form if you provide all necessary information.
- Include itemized bills and receipts.
Itemized bills and receipts should show:
If information is missing, you may write it on the bill yourself and sign your name. Note: Cancelled checks, cash register receipts or balance due statements are not acceptable substitutes for itemized bills.
- Name of patient and relationship to enrollee;
- Plan identification number of the enrollee;
- Name and address of person or firm providing the service or supply;
- Dates that service or supplies were furnished;
- Type of each service or supply; and
- The charge for each service or supply.
- Keep a copy for your records.
- Mail medical claims and supporting documents to the address below:
P.O. Box 30783
Salt Lake City, UT 84130-0783
- Mail Transplan/DME/Dialysis claims to:
P.O. Box 300
Independence, MO 64051-0300
For claims questions and assistance, call us at (800) 220-7898.