Forms

For Medica Advantage Solution and Medica Prime Solution (Cost) Members

Medica Advantage Solution

Plan management forms

Claim reimbursement forms for Medica Group Advantage Solution® members

If your plan includes reimbursement for claims, you can find your claim reimbursement forms below. At the top of each form, information about plan eligibility is included. If reimbursement for a service doesn't apply to your plan, your form won't be processed.

2021 Advantage Solution claim forms

Applies to Medica Advantage Solution PPO and Medica Advantage Solution with CHI Health PPO and HMO members only

2021 Advantage Solution PartnerCare claim forms:

Determinations, appeals, and grievances

Enrollment forms

Medica Prime Solution (Cost)

Plan management forms

Claim Reimbursement Forms for Medica Prime Solution® members

If your plan includes reimbursement for claims, you can find your claim reimbursement forms below. At the top of each form, information about plan eligibility is included. If reimbursement for a service doesn't apply to your plan, your form won't be processed.

2021 Prime Solution claim forms

Eyewear reimbursement claim forms:

Determinations, appeals and grievances 

Enrollment and change forms


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Last Updated: December 2021
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