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
Y0088_1001143
Last Updated: December 2021
Last Updated: December 2021