Appointment of Representative FormIf you need someone to file a grievance, coverage determination or appeal on your behalf, you can name a relative, friend, advocate, doctor or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.
To download a copy of Medicare's Appointment of Representative form,
If you want to appoint a representative, you should complete the Appointment of Representative form on the Medicare.gov website and mail it to:
KelseyCare AdvantageATTN: Member ServicesP.O. Box 841569Pearland, Tx 77584
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Equivalent Notice FormIf you need someone to speak to Member Services on your behalf, you can name a relative, friend or advocate your appointed representative. You and that person must sign and date a statement that gives the person permission to act as your appointed representative.
To download a copy of the Equivalent Notice form,
You can return the completed form via email, fax or mail:
Fax: (713) 442-5450
Coordination of Benefits FormAfter you enroll, if you have more than one medical plan, you can complete the Coordination of Benefits form. Having more than one medical plan may save on medical costs by coordinating your benefits. The information you provide will help us determine if your other medical plan is primary or secondary to your KelseyCare Advantage plan.
Go to the Coordination of Benefits Form.
Transition of CareDuring your first few months of membership, you may have questions about transitioning your care to KelseyCare Advantage network providers. If you are currently receiving care from non-KelseyCare Advantage network providers, please call Member Services at 713-442-CARE (2273) or
1-866-535-8343, 8:00 a.m. to 5:00 p.m., Monday through Friday. TTY/TDD users should call
For more information about KelseyCare Advantage's Transition of Care policy,click here. To go to the Transition of Care request form,
Order New or Replacement ID CardYour ID card shows information important to your health insurance coverage. You don’t need a new ID card every year. If you change plans, we will send you a new ID card.
For a new or replacement ID card, you may request one
here or contact a KelseyCare Advantage Member Services representative at one of the phone numbers below and a new ID card will be sent to the address on file for you.
713-442-CARE (2273) or toll free:
1-866-302-9336)8 a.m. to 8 p.m., seven days a week
Press 2 if you are a current member of KelseyCare Advantage
Press 1 if you have a question regarding your medical benefits
Reimbursement form for Part D DrugsBelow is a brief description of some of the situations you may submit a paper claim for reimbursement for your Part D drug expenses. For a full description and a complete listing of all situations refer to the Evidence of Coverage, Chapter 7, Asking the plan to pay its share of a bill you have received for covered services or drugs. Some of the situations you may submit a paper claim include:
When you send us your request for reimbursement, include a copy of your bill and documentation of any payment you have made. It's a good idea to make a copy of your bill and receipts for your records. Make sure you are giving us all the information we need to make a decision. You don't have to use our form, but it's helpful for our plan to process the information faster. Either download a copy of our KelseyCare Advantage/OptumRx Direct Member Reimbursement Form (click here) or call Member Services and ask for the KelseyCare Advantage /OptumRx Direct Member Reimbursement Form.
Mail your request for payment and the KelseyCare Advantage/OptumRx Direct Member Reimbursement Form together with any bills or receipts to this address:
OptumRxDirect Member ReimbursementPO Box 968021Schaumburg, IL 60196-8021You must submit your claim to us within 12 months of the date you received the drug.