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ILLINOIS NONPARTICIPATING FACILITATED PHYSICIANS AND PROVIDERS / INSURER OR HEALTH PLAN Demand for Arbitration Pursuant to Illinois Insurance Code, Section 356z.3a To: Name of Respondent: Address:

How to fill out illinois out-of-network demand for

How to fill out illinois out-of-network demand for

1. To fill out the Illinois out-of-network demand form, follow these steps:
2. Start by printing out a copy of the Illinois out-of-network demand form.
3. Fill in the claimant's personal information such as the name, address, and contact details.
4. Provide details about the insurance policy, including the policy number, group number, and insurance company name.
5. Indicate the date when the services were rendered, the name and address of the healthcare provider, and the type of services received.
6. Specify the total amount charged by the out-of-network provider and attach any supporting documents such as invoices or bills.
7. Describe the efforts made to obtain in-network care and why out-of-network services were necessary.
8. Sign and date the form, certifying that all the information provided is true and accurate.
9. Make a copy of the completed form and all supporting documents for your records.
10. Send the original form and relevant documents to the address specified on the form or as directed by your insurance company.

Who needs illinois out-of-network demand for?

1. The Illinois out-of-network demand form is typically needed by individuals who have received healthcare services from an out-of-network provider and need to submit a claim to their insurance company for reimbursement.
2. It is used when the insured individual was unable to find an in-network provider or required services that were only available through an out-of-network provider.
3. Anyone who has an out-of-network coverage in their insurance policy and receives services from an out-of-network provider in Illinois may need to fill out this form.

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