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Medical Claim Form for Group and Individual & Family Plans

Complete the claim form for each member submitting bills for reimbursement of covered services. To avoid any delay, be sure to answer each question completely. PLEASE ATTACH FULLY ITEMIZED BILLS AND PROOF OF PAYMENT.

Proof of payment includes:

  • Copy of cancelled check (front and back) or online bank statement
  • Copy of credit card statement or bank statement

NOTE:

  • Proof of payment on a Dr.'s prescription form is not acceptable.
  • Invoices are not acceptable forms of proof of payment.

Non-Medicare – Behavioral Health (MHN) – Claim Form

Behavioral Health (MHN) – Claim Form – English (PDF) 1MB 12/18/17

Group Member Grievance Form

Please explain in detail the circumstances that led to your dissatisfaction with Health Net. Please include the original copy of any claims or bills received which are related to your issue.

Out-of-Network Vision Claim Form (non-Medicare)

Out-of-Network Vision Claim Form – English (PDF) 512kB 06/27/17

Continuity of Care Assistance Request Form

Out-of-Pocket Maximum Notification

Out-of-Pocket Maximum Notification – English (PDF) 92kB 01/30/14

Mail Order Pharmacy

CVS Caremark Mail Order Pharmacy

Prescription Claims

Prescription Drug Claim Form (Medicare Members)

Prescription Drug Claim Form (Commercial Members)

Prescription Transition Form

Prescription Transition Form (Commercial Members)

Glossary of Health Coverage and Medical Terms

Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.