Get documents about "Sample Medicare Member ID Cards
Document Sample
Sample Medicare
Member ID Cards
Below are examples of the GHI and HIP Medicare ID cards a member may present
when coming into your office for care. For Customer or Pharmacy services, please
call the numbers on the back of the member’s card.
Sample GHI Medicare Member ID Cards
GHI Medicare Prescription Drug Plan
0954 www.ghi.com
GHI Medicare MEMBERS AND PROVIDERS: Call Customer Service at
PDP 1 877 444 7241 prior approval, member eligibility or benefit
for
questions. TTY/TTD users call 1 866 248 0640
.
MEMBER: JOHN G. SAMPLEPLACEHOLDER Submit all claims to: GHI PDP Plan, P.O. Box 1520 JAF Station
ID NUMBER: 12345678900 New York, NY 10116-1520.
Possession of this card does not certify coverage.
CAT Code:
Deductible:
Copay: Rx
Rx BIN#: 013344
Rx PCN#: 0020080229
Issuer#: (80840)
CMS#: S5966000
A Medicare Prescription Union Bug
Drug Plan CBP Group Health Incorporated XXXXXXXXX
GHI Medicare PPO I
0954 www.ghi.com
GHI Medicare MEMBERS AND PROVIDERS: Call Customer Service at
PPO I 1-866-557-7300 for prior approval, member eligibility or benefit
questions. TTY/TTD users call 1-866-248-0640.
For Prescription Drug services call: 1-877-444-7097.
MEMBER: JOHN G. SAMPLEPLACEHOLDER Call 911 in case of an emergency and contact Customer
ID NUMBER: 12345678900
Service within 48 hours or as soon as possible.
Network: GHI Medicare Choice PPO Submit Medical/Hospital claims to: GHI, P.O. Box 2830,
CAT Code: New York, NY 10116
Copay: PCP SPEC Submit Prescription drug claims to: GHI Medicare Choice PPO,
ER Rx BIN#: 013344 JAF Station, P.O. Box 1520, New York, NY 10116-1520.
Preventive Dental Rx PCN#: 0020080229
Preferred Network Issuer#: (80840) Certain services may require pre-authorization. Check
CMS#: H5528001 evidence of coverage. Medicare limiting charges apply.
Possession of this card does not certify coverage. Union Bug
CBP Group Health Incorporated XXXXXXXXX
GHI Medicare PPO Value
0954 www.ghi.com
GHI Medicare MEMBERS AND PROVIDERS: Call Customer Service at
PPO Value 1-866-557-7300 for prior approval, member eligibility or benefit
questions. TTY/TTD users call 1-866-248-0640.
For Prescription Drug services call: 1-877-444-7097.
MEMBER: JOHN G. SAMPLEPLACEHOLDER
ID NUMBER: 12345678900 Call 911 in case of an emergency and contact Customer
Service within 48 hours or as soon as possible.
Network: GHI Medicare Choice PPO Submit Medical/Hospital claims to: GHI, P.O. Box 2830,
CAT Code: KAA New York, NY 10116
Copay: PCP $0 SPEC $0 Submit Prescription drug claims to: GHI Medicare Choice PPO,
ER $50 Rx BIN#: 013344 JAF Station, P.O. Box 1520, New York, NY 10116-1520.
Rx See evidence of coverage. Rx PCN#: 0000000000
CIN#: DS15973T Certain services may require pre-authorization. Check
Issuer#: (80840) evidence of coverage. Medicare limiting charges apply.
No copayment for in-network CMS#: H5528000 Possession of this card does not certify coverage.
and out-of-network services.
Union Bug
CBP Group Health Incorporated XXXXXXXXX
Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies.
EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. EGH_PR_FLY_007271_MEDICAREMEMBERIDCARD
12/09
Sample Member Medicare ID Cards
Sample HIP Medicare Member ID Cards
HIP Part D New York Prescription Drug Plan
0954 www.hipusa.com
HIP Part D MEMBERS AND PROVIDERS:
New York (PDP) Call
0954 Customer Service at 1-800-HIP-TALK (1-800-447-8255)
www.hipusa.com
HIP Part D MEMBERS AND member eligibility or benefit questions.
for prior approval,PROVIDERS:
0954 www.hipusa.com
TTY/TTD users call 1-888-HIP-4TDD (1-888-447-4833).
MEMBER: New York D
JOHN G. SAMPLEPLACEHOLDER (PDP)
HIP Part Call Customer Service at 1-800-HIP-TALK (1-800-447-8255)
MEMBERS AND PROVIDERS:
ID NUMBER: 12345678900 for
Submit approval, member eligibility or benefit questions.
0954priorall claims to:
New York (PDP) Call Customer Service at 1-800-HIP-TALK (1-800-447-8255)
TTY/TTD users call 1-888-HIP-4TDD (1-888-447-4833).
www.hipusa.com
MEMBER: HIP Part
JOHN G. SAMPLEPLACEHOLDER D MEMBERS AND member Water Street, New York, NY
HIP Pharmacy Services, 55eligibility or benefit questions.
for prior approval,PROVIDERS:
Deductible: $295
New York
JOHN G. SAMPLEPLACEHOLDER (PDP)
ID NUMBER: 12345678900 10041-8190. Service at 1-800-HIP-TALK (1-800-447-8255)
Call Customer
TTY/TTD claims to:
Submit allusers call 1-888-HIP-4TDD (1-888-447-4833).
Copay: Rx
MEMBER:
ID NUMBER: 12345678900
for prior approval, card does not certify coverage.
Possession of this member eligibility or benefit questions.
HIP Pharmacy Services, 55 Water Street, New York, NY
Submit allusers to:
Deductible: $295 Rx BIN#: 400023 TTY/TTD claims
10041-8190. call 1-888-HIP-4TDD (1-888-447-4833).
MEMBER:
Copay: Rx JOHN G. SAMPLEPLACEHOLDER HIP Pharmacy Services, 55 Water Street, New York, NY
Deductible: $295
ID NUMBER: 12345678900 Rx PCN#: 0020050403 Submit all claims to:
Issuer#: (80840) 10041-8190.
Possession of this card does not certify coverage.
Copay: Rx Rx BIN#: 400023 HIP Pharmacy Services, 55 Water Street, New York, NY
CMS#: S5741 001 Possession of this card does not certify coverage.
A Medicare $295
Deductible: Prescription Rx PCN#: 0020050403
Rx BIN#: 400023
10041-8190.
Copay: Rx
Drug Plan Issuer#: (80840) Union Bug
Rx PCN#: 0020050403
CMS#: S5741 001
HIP Health Plan of New York
Possession of this card does not certify coverage.
XXXXXXXXX
A Medicare Prescription Rx BIN#:(80840)
Issuer#: 400023
Drug Plan CMS#: S5741 001
Rx PCN#: 0020050403 HIP Health Plan of New York
Union Bug
XXXXXXXXX
A Medicare Prescription Issuer#: (80840)
HIP Part D New York Prescription Drug Plan
Drug Plan CMS#: S5741 001 HIP Health Plan of New York
0954
Union Bug
XXXXXXXXX
www.hipusa.com
A Medicare Prescription
Drug Plan HIP VIP Dual All covered non-emergency services must be provided by Union Bug
HIP Health Plan of New York XXXXXXXXX
Eligible (HMO) or authorized
0954 by HIP. In case of non-emergency illness,
www.hipusa.com
HIP VIP Dual contact your PCP.
All covered non-emergency services must be provided by
MEMBERS AND HIP. In case of non-emergency illness,
or authorized by PROVIDERS:
0954 www.hipusa.com
MEMBER: Eligible Dual
JOHN G. SAMPLEPLACEHOLDER (HMO)
HIP VIP All covered non-emergency services must (1-800-447-8255)
Call Customer Service at 1-800-HIP-TALK be provided by
ID NUMBER: 12345678900 contact your PCP.
Eligible (HMO) forauthorized by PROVIDERS:
or
MEMBERS AND HIP. In case of non-emergency illness,
0954prior approval, member eligibility or benefit questions. www.hipusa.com
MEMBER: HIP VIP
JOHN G. SAMPLEPLACEHOLDER Dual All covered non-emergency services (1-888-447-4833).
TTY/TTD users call 1-888-HIP-4TDDmust (1-800-447-8255)
contact your PCP.
Call Customer Service at 1-800-HIP-TALK be provided by
PCP Name: Dr. John Smith Call 911 approval,PROVIDERS: non-emergency illness,
Eligible
JOHN G. SAMPLEPLACEHOLDER (HMO)
ID NUMBER: 12345678900 or prior in AND an emergency
MEMBERScase ofmember eligibility orcontact Customer
forauthorized by HIP. In case of and benefit questions.
PCP Phone: 000-000-0000
MEMBER: Service your PCP.hoursat 1-800-HIP-TALK (1-800-447-8255)
Call Customer 48 1-888-HIP-4TDD (1-888-447-4833).
contact within Service or as soon as possible.
Copay: PCP $0 SPEC $5
ID NUMBER: 12345678900 TTY/TTD users call
PCP Name: Dr. John Smith Submit all claimsofmember eligibility orcontact Customer
for prior approval,PROVIDERS: and benefit questions.
MEMBERScase to: emergency
Call 911 in AND an
ER $0
MEMBER: Rx BIN#: 400023
JOHN G. SAMPLEPLACEHOLDER
PCP Phone: 000-000-0000
Rx NUMBER:Dr. John Smith HIP, Customer2803, 1-888-HIP-4TDD (1-888-447-4833).
Call P.O. users call New 1-800-HIP-TALK (1-800-447-8255)
TTY/TTD Box 48 hoursat York, NY 10116-2803.
Service within Service or as soon as possible.
ID $10/$20/50%/25%/25%
PCP Name: 12345678900
Copay: PCP $0 SPEC $5
Rx PCN#: 0020050403
Call 911services may require pre-authorization.questions.
Certain all claimsofmember eligibility orcontact Customer
for prior approval,to: emergency and benefit
PCP Phone: 000-000-0000 Issuer#: (80840) Submit in case an
ER $0 Rx BIN#: 400023 Service within 2803, 1-888-HIP-4TDD (1-888-447-4833).
TTY/TTD Box 48of New York, NY as possible.
Copay: PCP Dr. John Smith
PCP Name: $0 SPEC $5
Rx $10/$20/50%/25%/25%
CMS#: H3330000 Check evidencecallcoverage. soon 10116-2803.
HIP, P.O. users hours or as
Rx PCN#: 0020050403 Call 911services to: emergency and contact
Submit all claimsmay require not certify coverage.
Possessioncase of card does pre-authorization.Customer
ER $0
PCP Phone: 000-000-0000 Rx BIN#: 400023
Issuer#: (80840) Certain in of this an
Service of Box
HIP, P.O. New York 48of coverage. soon as possible.
HIP Health Plan within 2803, New York, NY 10116-2803.
Union Bug
Preferred Health Partners
Rx $10/$20/50%/25%/25%
Copay: PCP $0 SPEC $5 Rx PCN#: 0020050403
CMS#: H3330000 Check evidence hours or as XXXXXXXXX
Issuer#: (80840) Certain all claimsmay require not certify coverage.
Possession of this card does pre-authorization.
Submit services to:
ER $0 Rx BIN#: 400023 Check evidence of coverage. NY 10116-2803.
Rx $10/$20/50%/25%/25% CMS#: H3330000 HIP, P.O. Box 2803, New York, Union Bug
Preferred Health Partners Rx PCN#: 0020050403 HIP Health Plan of New York XXXXXXXXX
Issuer#: (80840) Certain services may require not certify coverage.
Possession of this card does pre-authorization.
Union Bug
Preferred Health Partners CMS#: H3330000 Check evidence of coverage.
HIP Health Plan of New York XXXXXXXXX
0954
Possession of this card does not certify coverage. www.hipusa.com
HIP VIP Dual Eligible HMO
Preferred Health Partners HIP VIP All covered non-emergency services must be provided by or authorized by HIP. In case ofBug
HIP Health Plan of New York
non-emergency illness, CONTACT YOUR PRIMARY CARE PHYSICIAN whose number is the front
Union
XXXXXXXXX
(HMO) 0954 card. In case of emergency, go to the nearest emergency room or call 911. You should notify
of this www.hipusa.com
HIP within 48 hours from the start of receiving emergency care, or as soon as reasonably possible,
HIP VIP All covered non-emergency services must be provided by or authorized by HIP. In detailed
by calling 1-800-HIP-TALK (1-800-447-8255). (These instructions do not replace the morecase of
0954
non-emergency illness, CONTACT YOUR PRIMARYfound inPHYSICIAN whose number is the front
discussions on obtaining services CARE your HIP Contract.)
www.hipusa.com
MEMBER: (HMO)
HIP VIP
JOHN G. SAMPLEPLACEHOLDER of this card. In case of emergency, go tocarenearest not provided by or call 911. You should notify
VIP members: If you receive the that is emergency room or authorized by In case of
All covered non-emergency services must be provided by or authorized by HIP. HIP
HIP within 48 hours from the start of receiving emergency care, or as soon as reasonably possible,
(other than emergency or urgent care), neither CARE Medicare will pay for that service
non-emergency illness, CONTACT YOUR PRIMARYHIP norPHYSICIAN whose number is the front
ID NUMBER: 12345678900
(HMO)
www.hipusa.com
0954 card.1-800-HIP-TALK (1-800-447-8255). (These for paymentdo or call 911. Youmore detailed
by calling
of this and you will be responsible instructions ofnot replace the should notify
In case of emergency, go to the nearest emergency room care.
HIP VIP
discussions on obtaining services found in your HIP Contract.)
FOR MEMBERS:
All covered non-emergency INSTRUCTIONSis provided by or authorized by HIP. HIP
HIP within 48 hours from the start of receiving emergency care, or as soon as reasonably case of
services must be
VIP members: If you receive care that not HIP Customeror authorized by In
possible,
MEMBER: JOHN G. SAMPLEPLACEHOLDER MEMBER INQUIRIES–Please write or call the provided by Service Department,
by calling 1-800-HIP-TALK (1-800-447-8255). (These instructions do not replace the more the front
non-emergency illness, CONTACT YOUR PRIMARYHIP norPHYSICIAN whose number is detailed
CARE Medicare will pay for that service
PCP Name: Dr. John Smith Water than emergency NY 10041-8190 or call 1-800-HIP-TALK (1-800-447-8255)
neither
55 (other Street, New York, or urgent care),services found in your HIP Contract.)
ID NUMBER: 12345678900
PCP Phone: 000-000-0000
MEMBER: (HMO)
JOHN G. SAMPLEPLACEHOLDER
of emergency, obtaining
of this card. In casediscussions onwill to the nearest emergency room or call 911. You should notify
and you go be responsible for payment of care.
PLEASE USE YOUR start of receiving emergency care, or
VIP members: If the receive care that is NUMBER IN ALL soon as reasonably possible,
provided by COMMUNICATIONS
HIP within 48 hours from youHIP IDENTIFICATIONnotMEMBERS:asor authorized by HIP
INSTRUCTIONS FOR
INSTRUCTIONS FOR PROVIDERS
1-800-HIP-TALK (1-800-447-8255). call the HIP AND FACILITIES Department,
callingthan emergency or urgent care), or(These instructions do not replace the more detailed
by(otherMEMBER INQUIRIES–Please write neither HIP nor Medicare will pay for that service
Copay: PCP $0 SPEC $0
ID NUMBER: 12345678900 Customer Service
PCP Name: Dr. John Smith
ER $0
and you obtaining at 1-800-551-8201 for
EMERGENCY ROOMS–Contact Inspiris services found in your prior approval of all treatment
discussions onwill be responsible for payment of care.
York, NY 10041-8190 or call 1-800-HIP-TALK (1-800-447-8255)
55 Water Street, New following medical screening and stabilization,HIP Contract.)
MEMBER:Rx YJOHN G. SAMPLEPLACEHOLDER
PCP Phone: 000-000-0000
Rx BIN#: 400023 INSTRUCTIONSis notMEMBERS:if required.
PLEASE USEADMITTING–To verify that
receive care FOR provided by or authorized by HIP
VIP members: If youHIP IDENTIFICATION NUMBER IN ALL COMMUNICATIONS
HOSPITAL YOUR or call HIP nor Medicare 1-800-447-8255.
Rx PCN#: 0020050403 than emergency or urgent care), neithereligibility please call will pay for that service
(otherMEMBER INQUIRIES–Please write patient the HIP AND FACILITIES Department,
Customer Service
Copay: PCP Dr. John Smith
ID NUMBER: 12345678900
PCP Name: $0 INSTRUCTIONS FOR PROVIDERS to:
All claims call 1-800-HIP-TALK (1-800-447-8255)
SPEC $0 Issuer#: (80840)
55 Water Street, New York, NY 10041-8190 orshould be sent
and you will be responsible for payment of approval of all
EMERGENCY ROOMS–Contact Inspiris2127, Brentwood, care. 37024 treatment
INSPIRIS, P.O. Box at 1-800-551-8201 for priorTN
PCP Phone: 000-000-0000
ER $0 Rx Y Rx BIN#: 400023
PLEASE USE YOUR HIP IDENTIFICATION NUMBER IN ALL COMMUNICATIONS
INSTRUCTIONS and MEMBERS:
following STATUSscreening FORstabilization, if required.
CLAIM medical FOR PROVIDERS Customer Service
Copay: PCP Dr. John Smith
SPEC $0 CMS#: H3330000 INQUIRIES, CALL: 1-888-315-5442
INSTRUCTIONS write or call the HIP AND FACILITIES Department,
MEMBER INQUIRIES–Please
PCP Name: $0 Rx PCN#: 0020050403 HOSPITAL ADMITTING–To verify patient eligibility please call 1-800-447-8255.
EMERGENCY ROOMS–ContactHEALTHat call 1-800-HIP-TALK (1-800-447-8255)
FOR MENTAL Inspiris SERVICE
55 Water Street, New York, NY 10041-8190 orshould beCALL: 1-888-447-2526 of all treatment
1-800-551-8201 for prior approval
ER $0 Rx Y
PCP Phone: 000-000-0000 Issuer#: 400023
Rx BIN#:(80840) All this card
Possession ofclaims sent to:
and not certify coverage.
following medical screeningdoes stabilization, if required.
HIP Health Plan of New YorkADMITTING–To verify2127, eligibility please call 1-800-447-8255. XXXXXXXXX
INSPIRIS, P.O. Box NUMBER IN ALL TN 37024
PLEASE USE YOUR HIP IDENTIFICATION Brentwood, COMMUNICATIONS Union Bug
Copay: PCP $0 SPEC $0 Rx PCN#: 0020050403
CMS#: H3330000
HOSPITAL INSTRUCTIONS FORpatient
CLAIM STATUS INQUIRIES, CALL:AND FACILITIES
PROVIDERS 1-888-315-5442
All claims should be sent to:for prior approval of all treatment
EMERGENCY ROOMS–ContactHEALTHat 1-800-551-8201 1-888-447-2526
FOR MENTAL Inspiris SERVICE CALL:
ER $0 Rx Y Issuer#: (80840)
Rx BIN#: 400023 2127, Brentwood, TN
following medical screening and not certify coverage. 37024
INSPIRIS, P.O. Box card does stabilization, if required.
Possession of this
CMS#: H3330000
Rx PCN#: 0020050403
CLAIM STATUS INQUIRIES, CALL: please call 1-800-447-8255. Union Bug
HOSPITAL ADMITTING–To verify patient eligibility1-888-315-5442
HIP Health Plan of New York
FOR MENTAL HEALTH SERVICE CALL: 1-888-447-2526
XXXXXXXXX
All claims should be sent to:
Issuer#: (80840) Possession of this 2127, Brentwood, TN
INSPIRIS, P.O. Box card does not certify coverage. 37024 Union Bug
CMS#: H3330000 HIP Health Plan of New York CLAIM STATUS INQUIRIES, CALL: 1-888-315-5442
0954 FOR MENTAL HEALTH SERVICE CALL: 1-888-447-2526
XXXXXXXXX
www.hipusa.com
HIP VIP Medicaid HIP Health Plan of New York
Possession of this card does not certify coverage.
WHEN YOUR PRIMARY CARE PHYSICIAN’S OFFICE IS CLOSED AND EMERGENCY MEDICAL
Union Bug
XXXXXXXXX
Advantage (HMO)
CARE IS NEEDED or to obtain preauthorization for hospital admission, CALL 1-888-746-2200.
www.hipusa.com
0954 non emergency care must be provided or arranged by a provider participating with HIP Health
All
HIP VIP HMO HIP VIP Medicaid Plan of New York. For VIP members, neither HIP nor Medicare will cover care that is not provided or
WHEN YOUR PRIMARY CARE PHYSICIAN’S OFFICE IS CLOSED AND EMERGENCY MEDICAL
arranged by HIP (except obtain preauthorization for hospital admission, CALL in your contract).
0954 IS NEEDED or to for emergency care or out-of-area urgent care as defined www.hipusa.com
Advantage
OHN G. SAMPLEPLACEHOLDER (HMO)
CARE 1-888-746-2200.
MEMBER: HIP VIP Medicaid INSTRUCTIONS FOR by a provider
All non emergency care must PHYSICIAN’S OFFICE MEMBERS participating with HIP Health
WHEN YOUR PRIMARY CAREbe provided or arranged IS CLOSED AND EMERGENCY MEDICAL
or call Medicare
HIP Customer Service Department
Plan ofISMEMBER INQUIRIES–Please write HIP northehospitalwill cover care that is not provided or
ID NUMBER: 12345678900 CARE New York. For VIP members, neither
Advantage (HMO)
NEEDED or to obtain preauthorization for admission, CALL 1-888-746-2200.
0954 emergency care or out-of-area 10041-8190 www.hipusa.com
arrangedemergency carefor 55 Water Street, New York, NY a provider participating with HIP Health
All non by HIP (except must be provided or arranged by urgent care as defined in your contract).
MEMBER: HIP VIP Medicaid
OHN G. SAMPLEPLACEHOLDER
Call 1-800-HIP-TALK (1-800-447-8255)
INSTRUCTIONS FOR IS CLOSED
WHEN YOUR PRIMARY CARE PHYSICIAN’S OFFICE MEMBERScover care that is not provided or
Plan of New York. For VIP members, neither HIP nor Medicare will AND EMERGENCY MEDICAL
NUMBER IN ALL
PLEASE USE YOUR HIP IDENTIFICATIONthe HIP Customer COMMUNICATIONS
PCP Name: Dr. John Smith arranged NEEDED or to for emergency care or callfor hospital admission, CALL in your
CARE ISMEMBER INQUIRIES–Please write or out-of-area urgent careService Departmentcontract).
Advantage
OHN G. SAMPLEPLACEHOLDER (HMO)
by HIP (except obtain preauthorization as defined 1-888-746-2200.
ID NUMBER: 12345678900 INSTRUCTIONS FOR PROVIDERS AND FACILITIES
55 be provided or arranged NY a provider
INSTRUCTIONS York, by 10041-8190
All non emergency care must Water Street, New FOR MEMBERS participating with HIP Health
PCP Phone: 000-000-0000
MEMBER: All admissions require prior approval. To verify patient eligibility
Plan of New York. For VIP 1-800-HIP-TALK (1-800-447-8255) Department
Callmembers, neither HIP northe HIP Customer Servicethat is not provided or
MEMBER INQUIRIES–Please write or call Medicare will cover care
Copay: PCP $0 SPEC $0
ID NUMBER: 12345678900 call 1-800-447-8255. IN ALL COMMUNICATIONS
PLEASE USE YOUR HIP IDENTIFICATION NUMBER
emergency care or out-of-area urgent care
arranged by HIP (except for 55 Water Street, New York, NY 10041-8190as defined in your contract).
PCP Name: Dr. John Smith
ER $0 All claims should be AND to:
INSTRUCTIONS FOR PROVIDERS sentFACILITIES
MEMBER:Rx $2.50/$2.50 Rx BIN#: 400023
OHN G. SAMPLEPLACEHOLDER
PCP Phone: 000-000-0000
Call 1-800-HIP-TALK (1-800-447-8255)
INSTRUCTIONS FOR MEMBERS
HealthCare NUMBER IN
All admissions IDENTIFICATION Partners ALL Service Department
Rx PCN#: 0020050403 MEMBER INQUIRIES–Please write approval. To Customer COMMUNICATIONS
PLEASE USE YOUR HIPrequire prioror call the HIPverify patient eligibility
Copay: PCP Dr. John Smith
ID NUMBER: 12345678900
PCP Name: $0 SPEC $0 Issuer#: (80840)
1225 FranklinPROVIDERS Suite 100,
Avenue, 10041-8190
call 1-800-447-8255.
55 Water Street,
INSTRUCTIONS FORNew York, NY AND FACILITIES
PCP Phone: 000-000-0000
ER $0 Rx $2.50/$2.50 claims City, NYTo sent patient
AllGarden should be11530to: eligibility
Call 1-800-HIP-TALK (1-800-447-8255)
Rx BIN#: 400023
CMS#: H3330031002
All admissions require prior approval. verify
CLAIM STATUS INQUIRIES, CALL 1-888-746-2200.
HealthCare NUMBER IN
PLEASE USE YOUR HIP IDENTIFICATION Partners ALL COMMUNICATIONS
SPEC $0
Copay: PCP Dr. John Smith
PCP Name: $0 Rx PCN#: 0020050403 call 1-800-447-8255.
FOR MENTAL HEALTH SERVICES, CALL 1-888-447-2526.
1225 Franklin Avenue, AND to: Suite 100,
All claims should becertify coverage.
INSTRUCTIONS FOR PROVIDERS sentFACILITIES
ER $0 Rx $2.50/$2.50
PCP Phone: 000-000-0000 Issuer#: 400023
Rx BIN#:(80840) Possession of this card does not 11530
NYTo verify
Garden City, Partners patient eligibility
HealthCare
All admissions require prior approval. Union Bug
Copay: PCP $0 SPEC $0 Rx PCN#: 0020050403
CMS#: H3330031002
HIP Health Plan of New York
CLAIM STATUS INQUIRIES, CALL Suite 100,
1225 Franklin Avenue, 1-888-746-2200.
call 1-800-447-8255.
XXXXXXXXX
Issuer#: (80840) HEALTH City, NY sent
AllGarden should be11530to:
FOR MENTAL claims SERVICES, CALL 1-888-447-2526.
ER $0 Rx $2.50/$2.50 Rx BIN#: 400023 HealthCare CALL 1-888-746-2200.
Possession of INQUIRIES,Partners
CMS#: H3330031002
Rx PCN#: 0020050403 HIP Health Plan of New York
CLAIM STATUSthis card does not certify coverage.
1225 Franklin Avenue, Suite 100,
Union Bug
XXXXXXXXX
FOR MENTAL HEALTH SERVICES, CALL 1-888-447-2526.
Issuer#: (80840) Garden City, NY certify coverage.
Possession of this card does not 11530 Union Bug
CMS#: H3330031002 HIP Health Plan of New York CLAIM STATUS INQUIRIES, CALL 1-888-746-2200. XXXXXXXXX
FOR MENTAL HEALTH SERVICES, CALL 1-888-447-2526.
Possession of this card does not certify coverage. Union Bug
HIP Health Plan of New York XXXXXXXXX
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