HealthPlan Services (Payor ID # 59143) 2026

1. Click ‘Get Form’ to open the HealthPlan Services claim form in the editor.
2. Begin by filling out the Employee/Retiree Data section. Enter your name, address, and HealthPlan Services Member ID #, which starts with 'Q9'.
3. Next, complete the Patient Data section. Provide the patient's name, date of birth, age, and relationship to the employee.
4. Fill in the Other Insurance Data if applicable. Indicate if the patient is employed and provide details about any other health insurance coverage.
5. 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.
6. Complete and sign the Authorizations section to authorize payment directly to your chosen party.
7. 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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