Title
What is this for?
Contact Information
Member claim form for out of network behavioral health claims
Cigna Behavioral Health, Inc.
Attn: Claims Service Dept.
P.O. Box 188022
Chattanooga, TN 37422
To submit a claim for behavioral health expenses
Cigna Behavioral Health, Inc.
Attn: Claims Service Dept.
P.O. Box 188022
Chattanooga, TN 37422
Or follow mailing instructions on your ID Card
Colleague Group Reimbursement Claim Form
The Episcopal Church Medical Trust
19 East 34th Street,
New York, NY, 10016;
or fax to (212) 251-8891
To submit a claim for dental services
For mailing address, call Customer Service at number listed on your ID Card
To enroll a new employee or late enrollment in medical and/or dental plans
The Episcopal Church Medical Trust
19 East 34th Street
New York, NY 10016
Express Scripts Home Delivery Order Form (Active Employees)
EXPRESS SCRIPTS
PO BOX 747000
CINCINNATI, OH 45274-7000
To request reimbursement for covered medications purchased at retail cost
Send completed form with pharmacy receipt(s) to:
OptumRx Claims Department
P.O. Box 29044
Hot Springs, AR 71903
Out of Network Vision Services Claim Form
EyeMed Vision Care
Attn: OON Claims
P.O. Box 8504
Mason, OH 45040-7111
To submit a claim for medical expenses, or behavioral health expenses
Anthem Blue Cross and Blue Shield
PO Box 105187
Atlanta, GA 30348
To submit a claim for international medical expenses
To submit a claim for medical expenses
Mail form with itemized bills to Cigna address on your ID Card
To submit a claim for medical expenses
Kaiser Permanente Insurance Company (KPIC) Self-Funded Claims Administrator
P.O. BOX 30547
Salt Lake City, UT 84130-0547
Phone: (866) 213-3062
To authorize use or disclosure of your medical information
JoAnn Goetz,
Clinical Management
The Episcopal Church Medical Trust
19 East 34th Street
New York, NY 10016
Confidential Fax: (212) 592-1831