Claim Forms
Step 1: Fill out a claim for yourself
Submit a Claim Yourself
Please have your provider complete an HCFA–1500 form (non-hospital claims) for services you’ve paid for up front.
If the provider is unable to fill out the claim form, please follow the instructions below.
(use downloadable form below and make copies as needed)
Download a PDF file of the InsuranceTPA Claim Form
Instructions on how to fill out the Health Claim Form
View an example of a filled out Health Care Claim Form.
Step 2: If you have one of these plans, please use the correct form.
Accident Expense Plan
Download a PDF file of the InsuranceTPA Claim Form
Deductible Supplement Plan
Choose an option below:
- Janesville School District – DEDUCTIBLE SUPPLEMENT CLAIM FORM
- AUIC Members – AUIC DEDUCTIBLE SUPPLEMENT CLAIM FORM
If you have a hospital claim we require that the hospital submit the UB 92 CLAIM FORM for processing.
QHP Supplemental Plan
Download a PDF file of the InsuranceTPA Claim Form
Step 3: Make a copy for your records and mail to the following address.
InsuranceTPA.com
CLAIMS DEPARTMENT
14 N. Parker Drive
Janesville WI 53545
If you have claims questions about a submitted claim, your eligibility or your benefits, please call (800)-279-2290 or [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.
Claims Department