Medical Claim Pre-Estimate Form Instructions Complete all fields on form and sent to ConnectiCare Inc, 175 Scott Swamp Rd, Farmington, CT 06032, ATT: Claims Pre-Estimate or Fax form to (860) 409-2455.
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How to fill out the Medical Claim Pre-Estimate Form - ConnectiCare online
The Medical Claim Pre-Estimate Form from ConnectiCare is designed to provide users with a preliminary estimation of medical expenses. By following the detailed instructions below, you can easily complete the form online to ensure accurate processing of your medical claims.
Follow the steps to complete the Medical Claim Pre-Estimate Form online
- Press the ‘Get Form’ button to obtain the Medical Claim Pre-Estimate Form and open it using your preferred editing tool.
- Fill in the required Patient/Insured Information section. This includes the patient's identification number, the insured's full name (last name, first name, and middle initial), as well as their address.
- Specify the patient's relationship to the insured by selecting one of the options provided: Self, Spouse, Child, or Other. Then, enter the patient's name and date of birth.
- Indicate the patient’s sex by selecting Male or Female.
- In the Provider Information section, include the physician's full name, federal tax identification number, address, and National Provider Identifier (NPI) number.
- For the Medical Service Information, provide details such as the place of service, procedure codes (CPT/HCPCS), any modifiers, diagnosis code, charge amount, and the number of days or units required.
- In the Pre-Estimate Response Information section, choose how you would prefer to receive your pre-estimate response: via US Mail, e-mail, or fax. Fill in the respective contact information accordingly.
- Review all the entered information for accuracy and completeness. Remember that incomplete forms will be returned.
- Once all sections are duly filled out, save your changes. You can then download, print, or share the form as necessary before submitting it to ConnectiCare.
Get started on filing your Medical Claim Pre-Estimate Form online today!
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