Normally claims are submitted by the Piedmont network provider. Following that, the member will get a Piedmont statement regarding what was paid out by Piedmont to the provider and advising the member if they have any financial responsibility. However, if you use an "out of network" provider, or if you are in a situation when you have to pay "up front" for medical services and then need to be reimbursed, you will have to submit one or more of the below forms to Piedmont. You can download these printable Member Forms by clicking on the following:
4 Medical Claim Form Submit this form when filling a claim for an out-of-network provider, or for reimbursement for advance payment.
Prescription Claim Form
This is the Piedmont form to submit when filing a claim for prescription cost reimbursement.
Prescription Mail Order Form
This is the form you need to submit when requesting a 90-day supply of maintenance medication by mail (don't forget you can also use one of the "walk-in" 90-day supply participating pharmacies).
4COBRA Renewal Form
This is the form that you must fill out to continue to be enrolled in the COBRA administration plan.
HIPAA Release form
(General Authorization for Release of Confidential Information)
This form is required by Piedmont if a member would like his or her personal health care information shared with another party.
Dependent Out-Of-Area Form
This form needs to be submitted for all out-of-area covered dependents.
Appeal Request Form
This fillable form is used by members to request an appeal.
Transition of Care Request
This form must be submitted to advise us of care already established with an out of network provider or facility.
Appointment of Representative Form
This form must be submitted to Piedmont if the member would like to appoint a person to file a grievance, request a coverage determination or exception, or request an appeal on his or her behalf. The member and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request.