2013 myChoice Health Program (Choice)
2013 Member Forms
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.
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.
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
CDC Immunization Guidelines
My Online Services
Access your health care information & manage your personal health with our wellness tools.
Additional 2012 Health Benefit Information
Benefits Handbooks and References
Faculty & Staff Benefits Department Website
Vision Benefit administrator
Dental Benefit administrator
Medco website (Options)
Register to refill and renew prescriptions online, view pharmacy benefits
Medco Customer Service:
Express Scripts website (Choice & RHP)
Pharmacy information for Choice and RHP members
Learn more about services requiring prior authorization