Forms

For Medica Advantage Solution and Medica Prime Solution (Cost) Members

Medica Advantage Solution

Plan management forms

Claim and reimbursement forms

Applies to Medica Advantage Solution (HMO, PPO, HMO-POS, HMO I-SNP) and Medica Group Advantage Solution (PPO) members
Applies to Medica Advantage Solution (HMO, PPO, HMO-POS, HMO I-SNP) and Medica Group Advantage Solution (PPO) members
Applies to Medica Advantage Solution (HMO I-SNP) and Medica Group Advantage Solution (PPO) members
Applies to Medica Advantage Solution (HMO, PPO, HMO-POS, HMO I-SNP) and Medica Group Advantage Solution (PPO) members
Applies to Medica Advantage Solution (HMO, PPO, HMO-POS, HMO I-SNP) and Medica Group Advantage Solution (PPO) members

2021 Advantage Solution claim forms

Applies to Medica Advantage Solution PPO and Medica Advantage Solution with CHI Health PPO and HMO members only

2021 Advantage Solution PartnerCare claim forms:

Determinations, appeals, and grievances

Enrollment forms

Medica Prime Solution (Cost)

Plan management forms

Claim reimbursement forms

Applies to Medica Prime Solution (Cost) and Medica Group Prime Solution (Cost) members
Applies to Medica Prime Solution (Cost) and Medica Group Prime Solution (Cost) members
Applies to Medica Prime Solution (Cost) and Medica Group Prime Solution (Cost) members
Applies to Medica Prime Solution (Cost) and Medica Group Prime Solution (Cost) members

2021 Prime Solution claim forms

Eyewear reimbursement claim forms:

Enrollment and change forms

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