2025 Documents and Forms Library

2025 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 a pharmacy or vaccine administered in a provider’s office

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 Form
Complete this form to appoint someone as your representative. Both you and your representative need to sign this form.

*Health Insurance Portability and Accountability Act

Benefit Documents

HMO Basic

Mass Advantage Basic (HMO) Summary of Benefits

Mass Advantage Basic (HMO) Annual Notice of Changes

Mass Advantage Basic (HMO) Evidence of Coverage

HMO Plus

Mass Advantage Plus (HMO) Summary of Benefits

Mass Advantage Plus (HMO) Annual Notice of Changes

Mass Advantage Plus (HMO) Evidence of Coverage

PPO Premiere

Mass Advantage Premiere (PPO) Summary of Benefits

Mass Advantage Premiere (PPO) Annual Notice of Changes

Mass Advantage Premiere (PPO) Evidence of Coverage

PPO Extra

Mass Advantage Extra (PPO) Summary of Benefits

Mass Advantage Extra (PPO) Evidence of Coverage

Enrollment Forms

Complete Enrollment Kit (Ekit)

Enrollment Request Form

Pre-Enrollment Check List

Star Ratings

Star Ratings for HMO Plans

Star Ratings for PPO Plans

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) 

Multi-language Interpreter Services

Interoperability

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