myChoice Program

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2014 myChoice Health Program (Choice)

2014 myChoice Health Program (Choice) - Summary of Benefits


Member Forms

Authorized Representative
for Standard Appeals Form

You may authorize someone (for example afamily member, friend or health care provider) to act as your representative in your appeal process.

Medical Claim Form
Complete this form when seeking reimbursment for medical expenses
Flu Shot Reimbursement Form
If you obtain your flu shot from a provider who is not participating with Coventry Health Care, please note that you will be reimbursed up to the Medicare allowable for the flu shot. If the provider from whom you received your flu shot charges more than this, you will be responsible for the balance.
University of Missouri Pre-Authorization List
Effective 1/1/2014
Medical Member Designated Release of Information Form
Complete this form to identify other persons, such as a family members, to assist in handling or resolving questions regarding your MEDICAL benefits or payment for healthcare services they have received.
Physician Nomination Form
To nominate a provider who is not currently contracted with Coventry Health Care, complete this form and return to us.


Behavioral Health Forms

MhNet Member Designated Release of Information Form
Complete this form to identify other persons, such as a family members, to assist in handling or resolving questions regarding your BEHAVIORAL HEALTH benefits or payment for healthcare services they have received.
MHNet - Mental Health Member Claim Form
Reimbursment forms for services rendered from a participating network provider will be submitted directly to MHNet.
When seeking services with a non participating provider, please encourage the provider to call MHNet at the number listed on the back of your medical health plan identification card to obtain information on how they can submit claims to MHNet. If you have received services from a non-participating provider and you need to submit their claim(s) to MHNet for reimbursement, and/or you have paid for the services up front and would like to submit a claim for direct reimbursement to you, please comjplete the claim form below.


Member Tools

How To Read Your Explanation of Benefits (EOB)
My Online Services
Access your personal medical claim details, EOB's and Wellness tools
How To Locate a Provider
How To Locate a Provider instructions
Coventry Mobile Communications
Registered users of My Online ServicesSM, Coventry’s secure member website, have another way of accessing their health information and staying connected while on the go. Coventry Mobile, is now available in the app stores for free download and gives users quick and secure access to view/email or fax ID cards and other important information. Register now for My Online Services to access!


Preventive Health Guidelines

0 to 6 years
PDF
Clinical preventive services and immunization schedules for girls birth to six years.

Clinical preventive services and immunizations schedules for boys birth to six years.
7 to 12 years
PDF
Clinical preventive services and immunization schedules for girls seven to twelve years.

Clinical preventive services and immunizations schedules for boys seven to twelve years.
13 to 18 years
PDF
Clinical preventive services and immunization schedules for girls thirteen to eighteen years.

Clinical preventive services and immunizations schedules for boys thirteen to eighteen years.
19 to 30 years
PDF
Clinical preventive services and immunization schedules for girls nineteen to thirty-nine years.

Clinical preventive services and immunizations schedules for boys nineteen to thirty-nine years.
40 to 64 years
PDF
Clinical preventive services and immunization schedules for girls forty to sixty-four years.

Clinical preventive services and immunizations schedules for boys forty to sixty-four years.
65 and older
PDF
Clinical preventive services and immunization schedules for girls sixty-five and older.

Clinical preventive services and immunizations schedules for boys sixty-five and older.
Catch Up Schedule

My Online Services-Login or Register Now

To access your personal health care information, claims and benefits.

My Online Services

Access your health care information & manage your personal health with our wellness tools.

 

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Additional 2014 Health Benefit Information

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