Claim Submission Portal
Submit A Claim
Please enter patients copay card group and ID numbers.
Group #
OH9025031
Card ID
Please provide Patient’s EOB. If EOB does not contain the following please also attach supplemental documentation (e.g. completed 1500 form, 837, or UB04 form).
DOS
NDC
Quantity Dispensed
J Code
Drug Cost- listed as its own separate line item
The NPI of the facility where the therapy took place
Attach EOB File
Required
Attach Supplemental File
(Optional)
Note: If attached form(s) does not contain all information noted above then claim may be rejected and you will be contacted for supporting documentation.
Files must be jpg, gif, tif, png, or pdf with a maximum size of 5MB each
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