Sample Employee Id Card Template
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1Our ID Cards contain the information needed to
Sample ID Card
access your Health Plan Benefits.
The GROUP NUMBER is a unique
ID for your Employer’s Plan
FRONT OF CARD
The INSURED is normally the
ABC Co.
Employee
EMPLOYEE BENEFIT PLAN
θθ
LOGO
ZZZ
Group Number:
The ID NUMBER is a unique ID we
HOMER SIMSON
Insured:
assign to each Employee
θθθθ
ZZZ
1
ID Number:
MEDICAL and/or DENTAL
FAMILY
Medical Coverage:
COVERAGE shows the employee’s
FAMILY
DentalCoverage:
θ
election for the plan year.
PPO
For HealthSpan Provider Information:
HEALTHCARE PROVIDER PPO
513-551-1400 or 1-888-914-7726
info is normally in this section
Submit Claims to:
Electronic Payer ID:
CLAIMS
CLAIMS info
3737 West Fork Road
# 82056
is normally in this section
Cincinnati, OH 45247
RX
PHARMACY BENEFIT info
RxBIN 003858 Pharmacy Help Desk 1-800-235-4357
RxPCM A4
ESI Customer Service 1-800-451-6245
is normally in this section
RxGroup AJHE
BACK OF CARD
Contact for QUESTIONS & INFO
To Verify BENEFITS, ELIGIBILITY or CLAIM STATUS Contact: Custom Design Benefits.
is normally located here
513-598-2929 or 800-598-2929
Directions for Use: Please present your ID Card
TO EMPLOYEE
to your HEALTHCARE PROVIDER at each visit
This is your Benefit Identification Card. Carry it with you at all times and present it to the hospital or
– especially if you receive a new card. New info is
doctor whenever you or one of your eligible dependents plan to receive medical services. See your
often included on new ID cards.
employee booklet for a list of services your coverage provides.
All inpatient admissions must be authorized by HEALTHSPAN at (513)551-1400
Contact for CARE MANAGEMENT which
(Local) or 800-972-7726. Check your plan document for other authorizations required.
includes: Prior Authorization for Certain Services
TRAVELING outside your NETWORK service area – Contact GLOBAL CARE to locate a
(determined by your Plan) and Case Management
Provider or speak to a Registered Nurse at 866-807-6193.
for extra support during health issues.
Networks Available Outside
Your Network Service Area
Secondary
IN
MI
WHEN TRAVELING here in the U.S. and
In OH
abroad, you can call Global Care toll free to help
you find a healthcare provider or assist with an
All Other States
emergency.
Beech Street
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