Health Plans

Enrollment Forms
Title
What is this for?
Pages
To enroll in Medicare Supplement and dental plans if you are retired and enrolled in Medicare Part A and B.
2
Billing
Title
What is this for?
Contact Information
For employers to reconcile payment differences due to enrollment changes
Email: billingrecon@cpg.org Or fax to: (212) 592-9470
Billing Reconciliation (Instructions)
Email: billingrecon@cpg.org
Claims
Title
What is this for?
Contact Information
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 submit a claim for dental services
For mailing address, call Customer Service at number listed 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 prescription drugs
Express Scripts, Inc. P.O. Box 66583 St. Louis, MO 63166-6583 ATTN: NGC STD ACCTS
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
Prescription Claim Form for Medicare Part D
Express Scripts ATTN: Medicare Part D P.O. Box 14718 Lexington, KY 40512-4718 FAX: (608) 741-5483
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
Out of Network Vision Services Claim Form
EyeMed Vision Care Attn: OON Claims P.O. Box 8504 Mason, OH 45040-7111
Hearing Benefit Claim Form (UHC)
MAIL the Claim Form and the proof of payment attachments to: UnitedHealthcare, Atlanta Service Center, PO Box 740827, Atlanta, GA 30374
Submitting international travel claims for Retirees participating in Medicare Supplement plans only
Episcopal Church Medical Trust Travel Protection Benefit Coordinator PO Box 2745 New York, NY 10163
Medical Forms
Title
What is this for?
Contact Information
Notification to the Episcopal Church Medical Trust of the termination of a domestic partnership
Member Services The Episcopal Church Medical Trust 19 East 34th Street New York, NY 10016
To enroll your Child for coverage outside of the initial or annual Open Enrollment period
RETURN THIS COMPLETED FORM TO Medical Trust: The Episcopal Church 19 East 34th Street New York, NY 10016 Fax: (212) 592‐4234 Email: mtcustserv@cpg.org
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
To affirm a domestic partnership for benefits purposes
Member Services The Episcopal Church Medical Trust 19 East 34th Street New York, NY 10016
To maintain and organize personal health records and information
To change employee and/or billing information on individual health plans
The Episcopal Church Medical Trust 19 East 34th Street New York, NY 10016
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