Get Coordination Of Benefits Questionnaire - Qualchoice

Completing the Coordination Of Benefits Questionnaire is essential for ensuring accurate processing of your claims with QualChoice. This guide provides clear, step-by-step instructions to help you fill out the questionnaire correctly and efficiently online.

Follow the steps to complete the questionnaire accurately.

1. Press the ‘Get Form’ button to access the Coordination Of Benefits Questionnaire and open it in your document editor.
2. Begin with Section I: Subscriber Information. Enter your name as the QualChoice subscriber and your QualChoice ID number. Provide your contact phone number.
3. Indicate if you or any family members covered by QualChoice are also covered by another group health plan or Medicare. Check the appropriate box (Yes or No). If you select Yes, you will need to complete either Section II or Section III.
4. If applicable, proceed to Section II: Other Group Health Plan. Fill in the group health plan name, policy or group number, and the address of the plan. Include the name of the policyholder, effective date of coverage, date of birth, and zip code. If coverage has been canceled, provide the cancellation date.
5. List all family members who are also covered by the other group health plan, their relationship to you, and the parent responsible for coverage. Indicate if there is a court order for dependent coverage, if applicable.
6. If you checked Yes for Medicare in Section I, continue to Section III: Medicare Information. Attach a copy of the Medicare ID card. Indicate whether you are actively employed. List family members covered by Medicare and their Medicare ID numbers.
7. For each family member listed under Medicare, specify their eligibility and effective dates for Parts A, B, and D.
8. Complete Section IV: Authorized Signature. Acknowledge understanding of the statement regarding omissions or false information by signing and dating the form.
9. After filling out all applicable sections, review the form for completeness and accuracy. Save any changes you made during the process.
10. Finally, you can download, print, or share the completed form through your preferred method. Return the questionnaire to QualChoice via fax or mail to the address provided in Section V.

Start completing your Coordination Of Benefits Questionnaire online now to ensure your claims are processed accurately.