Claim Forms

Claim Forms

In certain circumstances, it may be necessary for you to submit a claim to be reimbursed for covered medical expenses you have incurred. You will provide information about you and your covered medical expense on a HCFA 1500 claim form. The link below will provide you with the correct form to submit your claim.

Please note all benefits are subject to the plan provisions and limitations in effect at the time of the service. For questions or further assistance in completing your claim form submission, please contact ACHIA Customer Service at 1-888-277-9133.