EMPLOYER NUMBER HIP CONTRACT CUSTOMER SERVICE CERTIFICATION COB ON THE CARD TRADITIONAL PRE- AUTHORIZATION MEDICARE ADVANTAGE TRICARE SUBSCRIBER PROVIDER SERVICES TO NOTIFY PRIOR TO OUT OF NETWORK CSHCS ELIGIBILITY EPO POLICY NUMBER MEDICARE PART A GROUP NUMBER GUARANTOR 1 & 99 ACCOUNT NUMBER GROUP NAME TRADITIONAL NEVER BENEFIT MRN AGE MRN SAGAMORE HEALTH BLUE CROSS/BLUE SHIELD OUT OF NETWORK VERIFICATION HOOSIER CARE CONNECT GROUP NUMBER PHCS PULSE WAIVER HEALTHSMART ESRD TRICARE TEMPLATE HOOSIER HEALTHWISE AUTHORIZATION 30 MONTHS ENCORE OA PLUS BIRTHDAY RULE COMMENTS ENCIRCLE WEB INTERCHANGE UNITED HEALTHCARE ANTHEM MSP EVERY TIME DISABILITY POS NOTIFICATION PPO HMO ADULT RULE ABN MEMBER SERVICE CIGNA ADD PERSON PATIENT SAFE SEARCH PRE- CERTIFICATION EMPLOYER NUMBER HIP CONTRACT CUSTOMER SERVICE CERTIFICATION COB ON THE CARD TRADITIONAL PRE- AUTHORIZATION MEDICARE ADVANTAGE TRICARE SUBSCRIBER PROVIDER SERVICES TO NOTIFY PRIOR TO OUT OF NETWORK CSHCS ELIGIBILITY EPO POLICY NUMBER MEDICARE PART A GROUP NUMBER GUARANTOR 1 & 99 ACCOUNT NUMBER GROUP NAME TRADITIONAL NEVER BENEFIT MRN AGE MRN SAGAMORE HEALTH BLUE CROSS/BLUE SHIELD OUT OF NETWORK VERIFICATION HOOSIER CARE CONNECT GROUP NUMBER PHCS PULSE WAIVER HEALTHSMART ESRD TRICARE TEMPLATE HOOSIER HEALTHWISE AUTHORIZATION 30 MONTHS ENCORE OA PLUS BIRTHDAY RULE COMMENTS ENCIRCLE WEB INTERCHANGE UNITED HEALTHCARE ANTHEM MSP EVERY TIME DISABILITY POS NOTIFICATION PPO HMO ADULT RULE ABN MEMBER SERVICE CIGNA ADD PERSON PATIENT SAFE SEARCH PRE- CERTIFICATION
(Print)
EMPLOYER NUMBER
HIP
CONTRACT
CUSTOMER SERVICE
CERTIFICATION
COB
ON THE CARD
TRADITIONAL
PRE-AUTHORIZATION
MEDICARE ADVANTAGE
TRICARE
SUBSCRIBER
PROVIDER SERVICES
TO NOTIFY PRIOR TO
OUT OF NETWORK
CSHCS
ELIGIBILITY
EPO
POLICY NUMBER
MEDICARE PART A
GROUP NUMBER
GUARANTOR
1 & 99
ACCOUNT NUMBER
GROUP NAME
TRADITIONAL
NEVER
BENEFIT
MRN
AGE
MRN
SAGAMORE HEALTH
BLUE CROSS/BLUE SHIELD
OUT OF NETWORK
VERIFICATION
HOOSIER CARE CONNECT
GROUP NUMBER
PHCS
PULSE
WAIVER
HEALTHSMART
ESRD
TRICARE
TEMPLATE
HOOSIER HEALTHWISE
AUTHORIZATION
30 MONTHS
ENCORE
OA PLUS
BIRTHDAY RULE
COMMENTS
ENCIRCLE
WEB INTERCHANGE
UNITED HEALTHCARE
ANTHEM
MSP
EVERY TIME
DISABILITY
POS
NOTIFICATION
PPO
HMO
ADULT RULE
ABN
MEMBER SERVICE
CIGNA
ADD PERSON
PATIENT SAFE SEARCH
PRE-CERTIFICATION
