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What is this form used for?

If a provider has failed to submit a claim on the member’s behalf; this form can be utilized by the member to submit their claims directly to Advisory Health Administrators. (Please note: Be sure to submit a separate form for each claim.)  


How is this form filled out?

Please visit a blank copy of the  Member Claims Form and complete each section in its entirety. If you print out the form to fill out by hand, please use black or blue ink and print clearly and legibly. You may also use your computer to complete this fillable form online to be printed and mailed to the email or U.S. Postal address below.

You will need to ask your provider for the Provider Information to be completed in section 4, rows C through G, or have them fill that out for you. You will also need to obtain a copy of the Superbill or Invoice from the provider that includes all of the following for each date of service:

  • Patient Name Diagnosis codes.
  • Procedure Codes (CPT, HCPC) – with any applicable modifiers.
  • Units for each procedure code.
  • The billed amount for each procedure code.
  • Place of service code.


IMPORTANT: This information must be on the Superbill as it is required to process the claim. Missing information can result in a delay or non-payment of the claim. Please be sure the information is clear and readable.

For services requiring prior authorization or notification please be sure to call the Member Services at 833-200-3095 which is also located on the back of your health plan ID card.


What happens next?

After we process your claim, we will send you an Explanation of Benefits (EOB). The EOB will explain the charges applied to your plan deductible and any charges you owe your health care provider. Please keep your EOB on file for future reference. 

                    
                                       Please submit completed form by email to csr@advisoryha.com or send by mail to:

                                         Advisory Health Administrators

                                                                                – PO Box 55611 Lexington, KY 40555 –

                                               Important: A submission of this claims form is not a guarantee of payment.

                                                                           Final determination is upon receipt of claim.


The Authorization for Release of Information form is required according to the guidelines set forth in the Health Insurance Portability and Accountability Act (HIPAA), specifically 45 CFR § 164.508 of the HIPAA Regulations.

Please visit this blank copy of the  HIPAA fillable form and following the description below of how to complete the form.

Section 1. Plan and member information

Section 2. Employee information: If you are NOT the employee of the plan

Section 3. Who you authorize to receive your PHI information; for example, spouse, child or friend

Section4. Purpose: Why do you want the information released?

Section 5. Your signature and your understanding of what it means

Section 6. Signature of member or member’s guardian

 

Please note:  All sections must be completely filled out and the member whose information is to be released is required to sign the authorization form for the form to be considered. 

         

                      Please submit completed forms by email to csr@advisoryha.com or mail:

             Advisory Health Administrators
           Attn: HIPAA Compliance Department
         PO Box 55611 Lexington, KY 40555


How can I help my claims be processed quicker?

Please provide us with any other healthcare coverages you and/or your dependents may have. Examples would include; another group plan, an individual policy, COBRA, Medicare, state programs (such as Medicaid, CHIP, etc.), Social Security benefitsdue to a disability, or medical expenses covered by another person due to a court order/decree.

You can provide this information by following this fillable  Other Insurance Coverage Form . You may fill out the form online via your computer or you may print a copy to complete by hand using a blue or black ink pen (please be sure to write clear and legible)   

    
     Please email completed forms to csr@advisoryha.com or you may submit the forms by U.S. mail to the address below:

            Advisory Health Administrators
                 ATTN: Eligibility Team
          – PO Box 55611 Lexington, KY 40555 –


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