Medical Insurance
Click on subject matter to see listing of forms
Directory of Provider Treatment Access Points
  (Doctors, Hospitals, Pharmacies under Group Plans)
Claim Forms
  Group Plans, Self-Administered Plans
Right of Conversion/Continuation
Disclosure
Prescription Drug Plan
State Variations

Medical Insurance

 
Doctors & Group Medical Plans Only: Directory of Preferred Hospitals Provider Organization (PPO) medical care access points contracted to provide care at pre-negotiated rates.
Pharmacies Group Medical Plans Only: Directory of pharmacies contracted to provide prescription drugs under group medical plans.

BACK TO TOP


Claim Forms

Group Plans

Pre-Treatment Review Certification Requirements: Explains process for pre-certifying non-emergency hospital stays and surgeries (other than doctor’s office).
Claim for Medical Expense Benefits: Form to be completed by employee, employer an doctor to file for medical benefits.

Authorization

Authorization to Obtain and Disclose Information .

BACK TO TOP


Right of Conversion

 
Notice of Right to Conversion of Medical Coverage: Form to send if employee or dependents want more information about continuing coverage.
Your Right to Continue Medical Coverage: Notice to employees and covered dependents about right to continue coverage due to family status or employment change.
Continuation of Group Medical: Form for employee to complete to continue group medical coverage.

BACK TO TOP


Disclosure

 
Disclosure of Information – Group Medical Plan: This form should be used with Certificate of Insurance to clarify and provide additional infomation about Medical plan benefits.

BACK TO TOP


Prescription Drug Plan

 
How The Prescription Plan Works.
Directory – Group Medical Plans Only – directory of participating pharmacies.

BACK TO TOP


State Variations

 

AZ - Arizona

AZ Arizona Appeals Process: How to appeal a pre-treatment review or claims decision.
AZ HealthCare Insurer Appeals Process information Packet: Notice from GLHIC about how to appeal decisions about pre-treatment review or claims.
AZ Disclosure of Information – Group Medical Plan: This form should be used with Certificate of Insurance to clarify and provide additional information about medical benefits.

CA - California

CA Notice of Second Medical Opinion Procedures: Notice to employees about the process of getting second medical opinions
CA Mandatory Notice: Notice to employees about maternity benefits
CA Mandatory Notice: Notice to employers and employees that a phone number to verify eligibility appears on the reverse side of the employee’s medical ID card

CT - Connecticut

CT Disclosure of Information – Group Medical Plan: This form should be used with the Certificate of Insurance to clarify and provide additional information about medical benefits.
CT Notice of Your Right To Continue Your Medical and Dental Coverage: Notice to employees about continuing coverage if family or employee status changes.
CT Continuance for Medical/Dental. Employees should use this form to request continuance of medical or dental coverage.

GA - Georgia

GA Important Notice of Your Rights When You Have A Baby: Notice of maternity and newborn coverage.
GA Disclosure of Information– Group Medical Plan. This form should be used with Certificate of Insurance to clarify and provide additional information about medical benefits.
GA Notice of Right of Enhanced Conversion of Medical Coverage: Notice to employee about conversion options if medical benefits terminate.
GA Medical Expense Conversion Policy Summary of Benefits: Description of benefit highlights if employee uses enhanced benefits conversion option.

ME - Maine

ME Emergency Hospital Admissions: Tells employers that emergency hospital admissions cannot result in lower benefits.
ME Third Party Notice. Employees can use this form if they wish a third party (relative) to be notified if coverage is terminated.
ME Notice of Admin Review. If reinstatement of coverage is denied due to organic brain disease, this notice says a third party (relative, attorney ) can be notified about the denial and right to appeal.

MA - Massachusetts

MA Important Notice About Your Rights When You Have A Baby.
MA Notice to Massachusetts Employers. Employers required to notify employees if medical or dental coverage will be cancelled and not replaced by self-insured or fully-insured plan.
MA Notice of Your Right to Continue Your Group Medical and Dental Coverage for firms insuring 20 or more lives. Notice to be distributed to employees.
MA Notice of Your Right to Continue Your Group Medical and Dental Coverage for firms insuring 2-19 lives. Notice to be distributed to employees.
MA Notice of Right to Conversion of Medical Coverage. Form to send if employee or dependents want more information on continuing coverage.
MA Continuance for Medical and/or Dental.Employees should use this form to request continuance of dental insurance.

MI - Michigan

MI Disclosure of Information – Group Medical Plan: This form should be used with Certificate of Insurance to clarify and provide additional information about medical benefits.

MN - Minnesota

MN Notice To Minnesota Employers: Requires written notice to employee if group Life, Disability or Medical coverage is cancelled and not replaced with a substantially similar coverage.
MN Notice of Continuation of Group Life, Medical and Dental Coverage: Notice to employees about coverage continuation should their family or employment status change.
MN Continuance of Medical/Dental/Life: form for both employers and employees to complete to continue coverage if family or employee status changes.

MO - Missouri

MO Additional Time Limits to Add Newborns to Coverage: Notice that employee has up to 10 days after receipt of all necessary enrollment forms to enroll a newborn for coverage.
MO Notice of Your Right to Continue Medical And/or Dental Coverage. Notice to employees about coverage continuation if their family or employment status changes.

NY - New York

NY Notice of Treatment of Breast Cancer Under New York State Insurance Law: Notice to employee describing coverage benefits for treatment of breast cancer.
NY Disclosure of Information – Group Medical Plan. This form should be used with Certificate of Insurance to clarify and provide additional information about medical benefits.
NY Notice of Your Right to Continue Medicaland Dental Coverage.

NC - North Carolina

NC Insurance Fiduciary Notice to employers about their responsibilities.

OK - Oklahoma

OK Notice of benefits about Wigs and Other Scalp Prostheses
OK Mandatory Notice: Informs employees of rights under the Oklahoma Breast Cancer Patient Protection Act.

SD - South Dakota

SD Important Notice of Changes in Maternity Coverage: Notice tells of state mandated hospital time limits for maternity coverage.

TX - Texas

TX Disclosure of information – Group Medial Plan:This form should be used with Certificate of Insurance to clarify and provide additional information about medical benefits.
TX Mandatory Notice: Tells of state mandated coverage for 102 Maternity, 258 Prostate, 349 Mastectomy and 1467 Colorectal Cancer.
TX Notice of Your Right To Continue Group Medical Coverage: Notice to employees about coverage continuations if their family or employment status change.

VA - Virginia

VA Disclosure of Information – Group Medical Plan: This form should be used with Certificate of Insurance to clarify and provide additional information about medical benefits.

WV - West Virginia

WV Notice of Women’s Direct Access to Health Care: Notice explains women’s rights to certain care without needing a referral from their primary care physician.

BACK TO TOP


Back