Claim Submission Form

Claim Submission Form
What type of claim are you submitting?
Medical Claim Form

Please Note: Only one claim per provider per member can be submitted. Each claim must be accompanied by an itemized bill from the facility or provider showing both procedure and diagnosis codes.
Dental Claim Form

Please Note: Only one claim per provider per member can be submitted. Each claim must be accompanied by an itemized bill from the facility or provider showing both procedure and diagnosis codes.
APPLICATION FOR VISION MATERIALS OR OUT-OF-NETWORK PROVIDER REIMBURSEMENT CLAIM FORM: Only one claim per provider per member can be submitted. This claim form must be accompanied by a copy of an itemized bill on provider letterhead to be eligible for plan reimbursement. You must complete each of the sections below.
Employee Information
Name

First NameMiddle NameLast Name
Sex
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marital Status
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Employer Name
Group Number (from your ID Card)
ERROR: Please enter a valid group number.
Type a question
Member Identification Number (from your ID Card)
Patient Information
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's Sex
Relationship to Participant

Other
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
In addition to coverage under this program, is the patient covered under any other insurance providing health care benefits or services?
Name of Insurer
Policy or Certificate Number
Effective Date of Coverage

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical Claim Information
Is this claim the result of an accidental injury?
To avoid delays in the processing of your claim, please also fill out the Accident Letter here.
Injury Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Where accident occurred and details:
Was the injury in any way work related?
Date of Service(s)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Provider of Service
Reimbursement should be provided to:
File Upload

(Limit of 5 files)
Cancelof
Please note:
- The total size of the uploaded files must be less than 28MB.
- Please ensure the file name length is 15 characters or less.
- Supported file types:
  DOC, DOCX, PDF, GIF, JPG, PNG, TIFF, or TIF.
  Files with non-supported file types renamed to supported ones will not be accepted. EXAMPLE: Renaming myreceipt.png to myreceipt.pdf
I certify that the above is complete and correct and that I am claiming benefits only for charges incurred by the patient above. Authorization is hereby given to any hospital, physician, or other provider which participated in any way in my care and
treatment to release to Cobalt Benefits Group any medical information which they in their judgment deem necessary to adjudicate this claim.
Participant Signature

Please sign with mouse or finger if on mobile device.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dental Claim Information

Dentist's Information
Name of Billing Dentist
TIN
Dental License #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
If prosthesis, is this the initial placement?
Date of Prior Placement

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Any reimbursement due should be made to:
File Upload

(Limit of 5 files)
Cancelof
Please note:
- The total size of the uploaded files must be less than 28MB.
- Please ensure the file name length is 15 characters or less.
- Supported file types:
  DOC, DOCX, PDF, GIF, JPG, PNG, TIFF, or TIF.
  Files with non-supported file types renamed to supported ones will not be accepted. EXAMPLE: Renaming myreceipt.png to myreceipt.pdf
I certify that the above is complete and correct and that I am claiming benefits only for charges incurred by the patient above. Authorization is hereby given to any hospital, physician, or other provider which participated in any way in my care and
treatment to release to Cobalt Benefits Group any medical information which they in their judgment deem necessary to adjudicate this claim.
Participant Signature

Please sign with mouse or finger if on mobile device.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Benefit Type
SELECT FROM THE BELOW:
File Upload

(Limit of 5 files)
Cancelof
Please note:
- The total size of the uploaded files must be less than 28MB.
- Please ensure the file name length is 15 characters or less.
- Supported file types:
  DOC, DOCX, PDF, GIF, JPG, PNG, TIFF, or TIF.
  Files with non-supported file types renamed to supported ones will not be accepted. EXAMPLE: Renaming myreceipt.png to myreceipt.pdf
I certify that the above is complete and correct and that I am claiming benefits only for charges incurred by the patient above. Authorization is hereby given to any hospital, physician, or other provider which participated in any way in my care and
treatment to release to Cobalt Benefits Group any medical information which they in their judgment deem necessary to adjudicate this claim.
ANY BENEFITS PAYABLE ARE DUE TO THE:
Participant Signature

Please sign with mouse or finger if on mobile device.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Rows	Date of Service	Tooth # or Letter	Procedure Code	Description
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Claim Submission Form

Employee Information

Patient Information

Medical Claim Information

Dental Claim Information

Dentist's Information

Benefit Type