When to Use This Form:
Use this form if you received services from a non-participating provider. Please submit a separate form for each billing provider.

If your provider is in-network, you do not need to submit this form. Your in-network provider will submit a claim on your behalf. Instead, use the Find a Doctor tool to verify if your provider is non-participating before proceeding.

What you’ll Need: 

Member ID Number

Details from your provider

Beyond the provider’s name and address, there are specific details needed that may appear on your bill or statement. If not, contact the provider before completing this form and request the following:

• Date of service – The date you received the medical service.
• Place of service – All allowed services have been provided in the dropdown on the form aligned to CMS.gov.
• National Provider Identifier (NPI) – A unique identification number given to your provider. This can be found on your bill or by asking your provider directly.
• Diagnosis code – A number used by your provider to explain the reason for your visit. Does not apply if place of service is Durable Medical Equipment. If you don't have the diagnosis code, you will need to provide the reason for the visit including, diagnosis, condition or symptoms.
• CPT/HCPCS (procedure/service codes) with any modifiers – Unique code used to describe the medical services received. If you don't have the CPT/HCPCS, provide the description or service performed.
• Amount charged – Amount charged is the total amount on the statement prior to any discounts applied.
• Amount paid – Amount paid by you to your provider for the service. This will allow us to reimburse you accordingly.

Proof of service and payment

You will be required to show proof of service and payment including any discounts received by uploading one of the following:

• Itemized statement from the provider showing any discounts provided and that the bill has been paid in full
• Receipt of payment 

Image files and pdf documents are allowed.