Non-Plan Provider Claim Form printable pdf download

Non-Plan Provider Claim Form

Member Instructions

IMPORTANT: Please review your applicable HPN Evidence or Agreement of Coverage for prior authorization

requirements. If you choose to receive Covered Services that are not certiﬁ ed by HPN’s Managed Care Program

when using a Non-Plan Provider, you may be responsible for all costs.

WHAT THIS FORM IS FOR: This form is used whenever covered healthcare services are obtained from a Non-

Plan Provider and a claim form must be ﬁ led with HPN in order that the Non-Plan Provider is paid for services

rendered. After your Non-Plan Provider Claim Form has been submitted and accepted by HPN, you will be

provided with a statement detailing the dollar amount applied to your annual Calendar Year Deductible and any

applicable maximum beneﬁ t limit.

HOW TO FILE A CLAIM: Most Providers will bill HPN directly. Before you submit a Non-Plan Provider Claim

Form to us, ﬁ nd out if it is necessary to do so. Many Providers will submit claims even if they are not contracted

with HPN. This is why it is important to show your Member ID Card at each appointment. If you are asked

by the Non-Plan Provider to submit the claim, please complete Section 1 only of the Non-Plan Provider Claim

Form. The Non-Plan Provider must ﬁ ll out Section 2 of the Non-Plan Provider Claim Form. Once the form is

completed, please submit to HPN’s Claims Department at the address provided below. Please include copies of

any applicable itemized bills and/or receipts from the Non-Plan Provider. The Non-Plan Provider’s itemized bill

must include the following information:

Name, Address, and Tax Identiﬁ cation Number;

Date of Service;

Diagnosis;

Description of Services and/or standardized codes rendered; and

Itemized charges for each service.

Items that will not be accepted for reimbursement include, but are not limited to:

Billing statements indicating balance due; or

Credit card receipts.

Completed Non-Plan Provider Claim Forms with copies of corresponding bills and/or receipts should be sent

to:

Mailing Address

Physical Address if Using Courier Services

Health Plan of Nevada

Attn: Claims Department (2720-4)

P.O. Box 15645

2720 N. Tenaya Way

Las Vegas, NV 89114-5645

Las Vegas, NV 89128-0424

Coordination of Beneﬁ ts (COB): If HPN is your secondary healthcare carrier, we must receive a completed

Non-Plan Provider Claim Form and a copy of the Explanation of Beneﬁ ts (EOB) statement for the billed charges

from your primary carrier in order to process your claim.

How Your Claim is Paid: If you authorize payment to the Non-Plan Provider, HPN will pay the Non-Plan

Provider directly. If you do not authorize payment to the Non-Plan Provider, HPN will pay you directly and you

will be responsible for payment to the Non-Plan Provider. HPN will provide you with an explanation of how the

Non-Plan Provider’s payment was determined.

For additional Non-Plan Provider Claim Forms: Please contact HPN’s Member Services Department at (702)

242-7300 or 1-(800)-777-1840, Monday – Friday, 8:00 AM to 5:00 PM Paciﬁ c Standard Time.

Form No. HPN-NV-ClaimForm (2006)

K:/NV2006/EnrollmentForms/HPN/Form #

PD-1856 (01/10)

Non-Plan Provider Claim Form

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