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Forms

For Medica Advantage Solution® (PPO and HMO-POS), Medica Advantage℠ (PPO) and Medica Prime Solution® (Cost)

Medica Advantage Solution and Medica Advantage

Plan management forms

Claim reimbursement forms for Medica Advantage 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.

Determinations, appeals, and grievances

Enrollment forms


Medica Prime Solution (Cost)

Plan management forms

Claim Reimbursement Forms for Medica Prime 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.

Determinations, appeals and grievances

Enrollment and change forms

Iowa

Kansas

Minnesota

Missouri

Nebraska

North Dakota and South Dakota

Oklahoma

Wisconsin

Wyoming

Medicare Plan Materials Order Form

Y0088_1009804_C
Last updated: April 2024