Hap Direct Payment Consideration Form

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Direct Payment Consideration Form
HAP Senior Plus (hmo), HAP Senior Plus (hmo-pos)
and Alliance Medicare PPO
Please use this form each time you submit a medical claim.
• Complete one form per family member.
• Keep a copy of all receipts and documents for your records.
• Allow 30 days for processing.
Step 1: Your Health Plan
 HAP Senior Plus
 Alliance Medicare PPO
Step 2: Patient Information: (Please Print)
Patient Name: _____________________________________________ID Number: _________________
Address: _________________________________________________Date of Birth: _______________
City, State, Zip: _______________________________________________________________________
Phone Number: ______________________________________________________________________
Step 3: Submission Information
a. Attach the itemized bill or statement that includes:
• Patient’s name
• Procedure and diagnosis codes
• Date of service
• Provider’s name, address
• Dollar amount charged for each service
• Provider tax identification number
If services were rendered out of the country please provide the reason for treatment:
_______________________________________________________________________________
b. Attach the proof of payment - please tape your receipt(s) to a separate sheet of paper.
Step 4: Submit to
HAP Claims Division
Member Reimbursement
2850 West Grand Boulevard
Detroit, MI 48202
For more information call us toll-free at: (800) 801-1770 for HAP Senior Plus or (888) 658-2536 for Alliance
Medicare PPO. TTY/TDD (800) 649-3777.
Our normal office hours are Monday – Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to noon. We have
extended hours from October 1st through February 14th, when Client Services Specialists are available
seven days a week from 8 a.m. to 8 p.m.
HAP Senior Plus (hmo), HAP Senior Plus (hmo-pos), and Alliance Medicare PPO are health plans with
Medicare contracts. Enrollment in the plans depends on contract renewals. Alliance Medicare PPO is a
product of Alliance Health and Life Insurance Company, a wholly owned subsidiary of HAP.
Y0076_HMO PPO 2014476 DIRECT CON
CMS ACCEPTED 12/22/2014
14-694

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