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HealthPlan Services (Payor ID # 59143) 2026
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- Click ‘Get Form’ to open the HealthPlan Services claim form in the editor.
- Begin by filling out the Employee/Retiree Data section. Enter your name, address, and HealthPlan Services Member ID #, which starts with 'Q9'.
- Next, complete the Patient Data section. Provide the patient's name, date of birth, age, and relationship to the employee.
- Fill in the Other Insurance Data if applicable. Indicate if the patient is employed and provide details about any other health insurance coverage.
- In the Physician or Supplier Information section, enter the provider's billing name, address, phone number, and Tax ID number. Include a description of the diagnosis and services provided.
- Complete and sign the Authorizations section to authorize payment directly to your chosen party.
- Finally, review all entries for accuracy before mailing or faxing your completed claim form along with itemized bills to HealthPlan Services.
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