ConnectiCare

Source: https://www.connecticare.com/-/media/Project/PWS/Microsites/ConnectiCare/PDFs/Members/out-of-plan-reimbursement.pdf

Read date: 10-09-2026

Research steps

1. Confirm that the plan includes an out-of-plan benefit. ConnectiCare's form identifies different underwriting and administration arrangements for HMO, POS, PPO, and ASO coverage. ConnectiCare Out-of-Plan Reimbursement Form
2. Complete Out-of-Plan Reimbursement Form F005 0519 in full, using one form for each claim. ConnectiCare Out-of-Plan Reimbursement Form
3. Attach the original itemized bill. It must show date of service, diagnosis or cause and nature of illness, procedure code or description, place of service, charges and payments, and the provider's full name, address, phone, Tax ID and/or NPI. A balance-due statement is not accepted. ConnectiCare Out-of-Plan Reimbursement Form
4. Select SELF in item 12 to request payment to the member. Select PROVIDER and sign item 14 only to request payment to the provider. Sign and date item 15. ConnectiCare Out-of-Plan Reimbursement Form
5. Portal upload NO. The claim form publishes only an offline route. Mental-health and substance-abuse claims are routed to OptumHealth Behavioral Solutions rather than the medical claims administrator. The offline destinations are intentionally omitted. ConnectiCare Out-of-Plan Reimbursement Form
6. Submit within six months, stated as 180 days on the form. NOT PUBLISHED: electronic-signature acceptance, CMS-1500 acceptance, processing time, or any member claim-upload mechanics. ConnectiCare Out-of-Plan Reimbursement Form
7. After processing, sign in to myConnectiCare, open Claims, and view the Health Plan Payment Summary or EOB. ConnectiCare Health Plan Payment Summary

Filing facts

• Portal upload: NO
• Portal: myConnectiCare for claim status only
• Portal path: NOT APPLICABLE: Out-of-Plan Reimbursement Form F005 publishes only an offline submission route
• Mail address: ConnectiCare Claims Department, P.O. Box 546, Farmington, CT 06034-0546 | MH: OptumHealth Behavioral Solutions, P.O. Box 30757, Salt Lake City, UT 84130-0757
• Fax: NOT PUBLISHED
• Attach: Date of service; diagnosis or cause and nature of illness; procedure code or procedure description; place of service; charges; payments made; provider full name; provider address; provider phone; provider Tax ID and/or NPI
• File types: NOT APPLICABLE
• File size limit: NOT APPLICABLE
• Maximum files: NOT APPLICABLE
• One file or separate files: NOT APPLICABLE
• Confirmation: NOT PUBLISHED
• Status check: myConnectiCare > Claims; Health Plan Payment Summary or EOB download
• Processing time: NOT PUBLISHED
• Member deadline: Within the last 6 months (180 days)
• Deadline basis: Published form applies across named ConnectiCare entities but product coverage and ASO terms can differ
• Mental health route: OptumHealth Behavioral Solutions is the published mental-health and substance-abuse claim administrator

Confirm the address, fax number or portal path on the insurer's own claims page before you send; read on 10-09-2026.