Update to Room Rate Notification Form

Many group and member benefits only provide for a semi-private room. The room rates on file are used to determine the patient's share when the difference between the private room and the semi-private room is the patient's responsibility. Therefore, the information you provide regarding your room rates assists us in adjudicating the claim with the correct patient share.

We have updated our Room Rate Notification Form . Submit this revised form to us when you need to make updates to the room rates at least 30 days prior to the effective date of the changes.