1. INet Claims
  2. Submit a request
NO HCFA-1500 OR UB-04 ORIGINAL OR CORRECTED CLAIM FORMS ARE ACCEPTED THROUGH THIS PORTAL, PLEASE SEE NEW CLAIM FAQ ON INTEGRANET HOME PAGE

Submit a request

All Submissions must include an attached Reconsideration/Appeal Request Form.
Request submitted without a Reconsideration/Appeal form will be considered an invalid submission.
Non-Contracted Providers must include a completed Waiver of Liability Form for Reconsideration/Appeal request.