The following forms will help you. Please click on each document to download. If you need assistance or have questions, please call Member Services toll free at 1-833-742-3125, (TTY 711). We are available October 1 – March 31, 8 a.m. to 8 p.m. Mountain Time (MT) daily; and, April 1 – September 30, 8 a.m. to 8 p.m. Mountain Time (MT) Monday through Friday.
Member Medical Claim Reimbursement Form
Use this form to request a medical reimbursement for something you have paid out-of-pocket but you believed should have been covered by El Paso Health Medicare Advantage.
Appoint a Representative Form (CMS 1696)
Appoint a Representative Form (CMS 1696) – Large Print
Appoint a Representative Form (CMS 1696) – Versión en Español
An appointed representative is a relative, friend, advocate, doctor, or other person authorized to act on your behalf in obtaining a grievance, coverage determination, or appeal. If you would to appoint a representative, you and your appointed representative must complete this form and mail it to El Paso Health Medicare Advantage at:
El Paso Health Medicare Advantage Dual (HMO D-SNP)
P.O. Box 971100
El Paso, TX 79997-1100
Member Grievance and Appeal Request Form
Member Grievance and Appeal Request Form – Versión en Español
Coverage Determination Request Form
Use this form to request coverage for a drug that is not on the formulary (a formulary exception), an exception to a quality limit, a lower copayment for a drug on the formulary or reimbursement for a covered drug that you purchased out-of-pocket.
You have the right to ask us for a redetermination (appeal) of our decision. Please use this form to request a redetermination (appeal).
Use this form to request a pharmacy reimbursement for something you have paid out-of-pocket but you believed should have been covered by El Paso Health Medicare Advantage.
