Documents and Forms Library

Documents and Forms Library

Claims

Medical Claims Reimbursement
To request repayment for a medical service

Pharmacy Claims Reimbursement
To request repayment for a prescription filled at the pharmacy

Dental Claims Reimbursement
To request repayment for a dental service

Vision Claims Reimbursement
To request repayment for a vision service

HIPAA Request Information*

Appointment of Representative Instructions
How to appoint someone other than yourself--such as a relative, friend, advocate, or attorney--to act on your behalf.

Appointment of Representative
Complete this form to appoint someone as your representative. Both you and your representative need to sign this form.

Protected Health Information (PHI) Release
Complete this form to allow us to share specific health information, otherwise protected, with an individual or entity you clearly authorize. 

Substance Use Disorder (PHI) Release 
Complete this form to allow us to share your substance use disorder information with an individual or entity.

*Health Insurance Portability and Accountability Act

Benefit Documents

HMO Basic

Mass Advantage Basic (HMO) Summary of Benefits

Mass Advantage Basic (HMO) Evidence of Coverage

Mass Advantage Basic (HMO) Annual Notice of Changes

Mass Advantage Basic (HMO) Part B Prescription Drugs Addendum (effective 4/1/2023)

HMO Plus

Mass Advantage Plus (HMO) Summary of Benefits

Mass Advantage Plus (HMO) Evidence of Coverage

Mass Advantage Plus (HMO) Annual Notice of Changes

Mass Advantage Plus (HMO) Part B Prescription Drugs Addendum (effective 4/1/2023)

PPO Premiere

Mass Advantage Premiere (PPO) Summary of Benefits

Mass Advantage Premiere (PPO) Evidence of Coverage

Mass Advantage Premiere (PPO) Annual Notice of Changes

Mass Advantage Premiere (PPO) Part B Prescription Drugs Addendum (effective 4/1/2023)

Enrollment Forms

Complete Enrollment Kit (Ekit)

Enrollment Request Form

Pre-Enrollment Check List

Plan Comparison Guide

Additional Member Information

Getting Care During a Disaster
Learn more about how to get care during a disaster.

Low Income Subsidy (LIS) Rider
This document shows how much lower a member's monthly premium will be if they are getting extra help from Medicare in paying for their Medicare prescription drug plan. 

If you are not receiving extra help but think you may qualify, you can research whom to contact to find out more.

Best Available Evidence (BAE)
CMS created the "best available evidence" process requiring plans to establish appropriate cost-sharing for low-income members when presented with evidence that the member's information was not accurate. More information can be found on the Medicare website. 

Authorization Agreement for Automatic Withdrawl (ACH) 

Interoperability

Interoperability Developer Toolkit
Information for developers on how to connect to the Mass Advantage interoperability code suite.