For members

Medical Claim Form

Dental Claim Form

Vision Claim Form

FSA Claim Form

Short-Term Disability Form

Other Insurance Coverage Form

Request for Predetermination Form

Request for Infusion Drug Authorization

HIPAA Form

HIPAA Form (Sp)

The Authorization for Release of Information form is required according to the guidelines set forth in the Health Insurance Portability and Accountability Act (HIPAA), specifically 45 CFR § 164.508 of the HIPAA Regulations.

The following is a description of how to complete the form.

Section 1.  Plan and member information
Section 2.  Employee information: if you are NOT the employee of the plan
Section 3.  Who you authorize to receive your PHI information; for example, spouse, child or friend
Section 4.  Purpose: why do you want the information released?
Section 5.  Your signature and your understanding of what it means
Section 6.  Signature of member or member’s guardian

The member whose information is to be released is required to sign the authorization form.

All sections of the form must be complete for the form to be considered. Please forward this completed form to the privacy officer of the employer or to:

Meritain Health
Attn: HIPAA Compliance Officer
PO Box 853921
Richardson, TX 75085

About Meritain Health’s Claims Appeal

Appeal Request Form

Meritain Health’s claim appeal procedure consists of three levels:

• Level 1-Internal appeal. If a member submits a claim for coverage and it is initially denied under the procedures described within the group plan document, that member may request a review of the denial. Meritain Health allows 180 days after a member receives notice of an initial adverse determination to request a review of the adverse determination.
• Level 2-Internal appeal. Meritain Health allows 60 days to request a second-level appeal after a member receives notice of an adverse determination at the first level of appeal.
• Level 3-External appeal. If a member has exhausted the benefit plan’s internal appeal process (or a member is eligible to request an external review for any other reason) that member may request an external review of the benefit plan’s final adverse determination for certain health benefit claims. Meritain Health requires the member to complete an appeals form to indicate a request for external review. Once we receive the request form, the request for external review will be handled in accordance with federal law and/or state law, depending upon the benefit plan.

There are two forms listed below that a member must complete and give to the provider submitting the formal written appeal. The formal written appeal and these forms would then be sent to the address of the Meritain Health Appeals Department (listed on form) by the provider. Submission of these forms to the Meritain Health Appeals Department without a formal written appeal from the provider will not be reviewed.

Please note, the claims appeal procedure is explained at length within each group’s Summary Plan Description (SPD).

The form linked below should used by a member who would like to grant permission to another individual to act on their behalf in connection with an appeal.

Appeal Authorization Release Form

Appeal Authorization Release Form (Sp)

The form linked below should be completed by a member who needs to grant access to their PHI to another individual in connection with an appeal.

HIPAA Form

HIPAA Form (Sp)

This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.

Transition or Continuity of Care

Transition or Continuity of Care (in Spanish)