In general, participating providers will submit claims directly to us on your behalf for provided services. However, there can be times when you, the member, need to submit a claim for reimbursement. For example, when you receive care from a non-participating provider for medical emergency care.
To submit a claim, please fill out our Member Reimbursement Form that is applicable for your plan and follow the instructions below.
PPO Plans Reimbursement Form
HMO Plan Reimbursement Form
1. Submit a claim only when you are billed for services from a provider that does not directly submit a claim to Allegian Choice.
2. Submit a separate form for each patient.
3. Attach an original itemized bill from your provider (required information is on the second page of the form).
4. Keep a copy of all bills and claim forms submitted (originals will not be returned).
5. Be sure to sign and date the completed form.
6. A member will be reimbursed for a covered health service for which he/she is required to make full payment at time of service. For claims to considered for reimbursement by Allegian Choice, they must meet the member’s package criteria. (If a service is obtained that is normally not a covered benefit under the member’s benefit package, it would not be a service eligible for reimbursement.) Refer to your “Certificate of Coverage” (COC) or “Evidence of Coverage” (EOC) for details of your benefits package.
7. Mail this claim form and all attachments to:
Allegian Choice Claims
c/o – Conifer Value-Based Care
P.O. BOX 6752
Annapolis, MD 21401
You and your spouse may be eligible fitness reimbursement if you both joined any of the Federal Exchange Allegian Choice health plans. You must be an active member of a qualifying fitness center, and complete 50 visits during six consecutive months of your coverage. Facility requirements also apply. Please review the Fitness Reimbursement Instructions for full details.
Fitness Reimbursement Form
Steps to Apply for Reimbursement:
1. Pick a qualifying fitness center, and visit at least 50 times during a period of six consecutive months.
2. Complete the form (use a separate form for each member).
3. Attach the following items:
- A copy of your current membership bill. It must show the amount you paid for membership.
- A copy of a receipt or documentation that shows you paid for each of the six months. This could include a credit card statement, payroll deduction, or automatic bank withdrawal. Receipts with price only are not valid. Please cross out any personal account identification information not relevant to your reimbursement.
- A brochure that describes the services of the fitness center, and
- Proof of your 50 visits, all within your coverage period. This includes: a computer print out of your visits, receipts that show individual visits to the gym, or verification from your employer that indicates your use of the employer’s gym.
4. Mail your completed form, copies of your membership bill and receipts, gym brochure, and proof of visits to:
Allegian Choice Financial Services
c/o Conifer Value-Based Care
PO Box 6752
Annapolis, MD 21401