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Master Medical Claim — Checklist

Before you submit a claim for Master Medical services, check with your doctor. Your Master Medical services will be processed automatically when your doctor submits a claim with both Basic and Master Medical services. When this happens, your doctor is sent a check for the covered Basic services and you are sent a check for the covered Master Medical services.


When you file for Master Medical benefits, please follow these guidelines:

  1. Note that your level of benefits will depend on the coverage you have through your group plan.
  2. Do not delay submitting services for payment. File a claim each time you receive covered services. Claims submitted more than 180 days after the end of the year in which the services were provided are not eligible for payment.
  3. Fill out the Master Medical Claim Form completely.
  4. Attach the original receipts from your provider. We cannot accept cash register tapes, cancelled checks or money order stubs. We cannot return the receipts to you. Be sure to send us the original receipts and keep the copies for yourself.
  5. Be sure your receipts and claim forms contain:
    • Subscriber's (card holder's) name and contract number
    • Patient's name
    • Date of service
    • Provider name, address, and Tax Identification number
    • Description of service (HCPCS or Procedure Code)
    • Diagnosis
    • Charge (itemize charges if more than one service is on a receipt)

Mail the claim form and receipts to the address printed on the bottom right corner of the claim form.