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HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA 1. MEDICARE MEDICAID TRICARE CHAMPUS (Sponsor's SSN) CHAMPVA GROUP HEALTH PLAN (SSN or ID) FECA BLK LUNG (SSN) SEX.

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This insurance is also known as: Formerly Heritage New York Medical Group. HEALTHCARE PARTNERS MEDICAL GROUP Other ID's: 23856.

Two companies from those early days of health insurance, Group Health Incorporated (GHI) and Health Insurance Plan of Greater New York (HIP), would later merge and become EmblemHealth.

Mailing Addresses Medical, Member submitted claims: P.O. Box 3000, NY, NY 10116-3000. Medical, Provider submitted claims: P.O. Box 2832, NY, NY 10116-2832. Hospital Claims: P.O. Box 2833, NY, NY 10116-2833. Dental Claims: P.O. Box 2838, NY, NY 10116-2838.

Mental health benefit EmblemHealth's HIP HMO Preferred Plan covers mental health and substance abuse programs and services, with confidential help available 24/7.

How to fill out a CMS-1500 form The type of insurance and the insured's ID number. The patient's full name. The patient's date of birth. The insured's full name, if applicable. The patient's address. The patient's relationship to the insured, if applicable. The insured's address, if applicable. Field reserved for NUCC use.

The only acceptable claim forms are those printed in Flint OCR Red, J6983, (or exact match) ink. Although a copy of the CMS-1500 form can be downloaded, copies of the form cannot be used for submission of claims, since your copy may not accurately replicate the scale and OCR color of the form.

Our Electronic Payer ID is 13551.

Claims Contacts CompanyNetworkPaper Claim Submission AddressEmblemHealth Plan, Inc. (formerly GHI)GHI PPO DentalEmblemHealth PO Box 2838 New York, NY 10116-2838ConnectiCareChoice Flex PassageConnectiCare PO Box 4000 Farmington, CT 06034-40005 more rows

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  • republished
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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232