Claim Forms
Accident Expense Plan
Download a PDF file of the InsuranceTPA Claim Form
Smart Accident Plus & Gap Assurance Plan Customers use ONLY the Form above, all others, use the forms below.
HCFA–1500
Please complete a HCFA-1500 form for non-hospital services you’ve paid for up front. Please follow the downloadable form and instructions below.
Smart Accident Plan & GAP Assurance Plan customers must obtain a completed HCFA-1500 from the rendering provider.
UB-04
Please complete a UB-4 form for hospital services you’ve paid for up front. Please follow the downloadable form and instructions below.
Smart Accident Plus & GAP assurance Plan Customers must obtain a completed UB-04 from the rendering facility.
Make a copy for your records and mail claims submission to the following address.
InsuranceTPA.com
CLAIMS DEPARTMENT
14 N. Parker Drive
Janesville WI 53545
Or Use the Customer Document Uploader on the Current Members Page.
If you have claims questions about a submitted claim, your eligibility or your benefits,
please call the number on the back of your ID card or email [email protected].
The hours of operation at InsuranceTPA.com, Inc Customer Service are 8:30 am – 5:00 pm CT Monday-Friday.
Thank you!
InsuranceTPA.com, Inc.