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Claim Instructions

	Claims Administrator FAQs Medical Claims Dental Claims Vision Claims Helpful Tips *You will need Adobe Acrobat Reader 5 to download and view the following claim forms. If you do not have Adobe Acrobat Reader 5, you can download it free of charge by clicking on the following icon:

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Medical Claims

PPO Providers are required to submit claims for you.

Non-PPO Providers may or may not submit claims for you. If they do not, please download and complete the claim form below. Ask the provider for a HCFA 1500 form or a "Super Bill." (This bill will provide complete details on your diagnosis, procedures, services and physician identification)

Medical Claim Form

Dental Claims

Many dental offices will submit claims for you. If your dentist does not, please download and complete the claim form below. If you are anticipating significant dental work, you can take this form to the dental office and ask for a Pre-Treatment estimate.

Dental Claim Form

Vision Claims

Vision Care Providers may not file your claim. Please use the Medical Claim Form to submit your vision claims. Please include a receipt that identifies the vision services provided, the date of service and the name of the provider.

Vision Claim Form

Helpful Tips

Here are some tips to help you get the best possible claims service from Intercare.

Always Make sure each physician, dentist, clinic, hospital, etc., you use makes a copy of your health care ID card. Your card gives billing representatives all the information they need to file your claim.
Anytime you mail or fax anything to your third party administrator, write your group number and your social security number on all documents. This is the best safeguard against lost or mislaid claims.
Organize your personal records by keeping one file with all of your bills in chronological order and a second file for the EOBs (explanation of benefits) you receive from your third party administrator. This will allow you to track what has been paid and alert you to potential problems.
If you receive an EOB you do not understand, call your third party administrator's customer service department for assistance.
If you have additional coverage with your spouse, be sure the administrator has that information. One simple way to be sure is to submit a completed claim form, making sure the line asking if you are covered by any other group insurance is completed.
If you submit an injury-related claim, you will receive a letter asking you to outline the details of the accident. Be sure to complete this form and return it promptly to avoid claim delays.
Our plan covers children through the age of 19 unless they are full-time students, who are covered to age 25. The administrator will request verification of student status each semester. You can avoid claim delays by sending a copy of your student's registration form to them at the beginning of every semester. Again, be sure your group number and social security number are on anything that you send.
When submitting non-PPO provider claims, be sure to mark the claims NON-PPO in order to speed up the processing time.

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Employee Benefit Service Center