In completing the required claim form, please ensure that the following items are indicated:
- Name of patient
- Type of Service (CPT code)
- Date of Service
- Charge for each service
- Diagnosis information (ICD-9 code)
- Physician’s stamp or signature
- Member’s signature is required
- A separate claim is required for each claimant
Claims must be submitted within three (3) months of the date of service. It is best to submit claims as soon as they are incurred.