Use this form to ask questions about a claim payment or benefit coverage you believe may be in error.

Personal Information

Name :
Company :
Address :
City :   State :   Zip :
Contact Phone :   and/or   E-mail :

If not you, who is the patient?
What is your relationship to this individual?

Patient's ID Number :

Claim or Benefit Information

Is this regarding   Dental   or   Vision ?

Enter your inquiry here

Please give a full description, including specific examples, procedures, the suspected error, what you believe it should reflect, etc. The more information you provide, the faster we may reply.