INSURER FILING GUIDE
UniCare State Indemnity Plan
Use this public information to prepare your packet, then confirm the route on the insurer's own page.
AT A GLANCE
Claim facts
| Member form | Medical Claim Form Number: 107293MAMENWLP Revision: 2024-06 (printed in month/year order) Open the insurer form |
|---|---|
| Portal upload | NO |
| Portal path | NO: the current form and 2026-2027 Total Choice handbook publish only a nonportal submission route |
| Mail address | Wellpoint, P.O. Box 4095, Woburn, MA 01888 |
| Fax | Not published by the insurer |
| Attachments | Provider name and address; patient name; service provided; date of service; amount charged for each service; diagnosis code; procedure code; Tax ID; proof of payment |
| Deadline | 2 years after the service date |
| Outcome and status | Wellpoint member account > Check on my claims |
| Processing time | Not published by the insurer |
| Caveats | UniCare in Massachusetts is now Wellpoint. Total Choice permits any doctor or hospital, but benefits and member cost depend on the current GIC plan. Medicare Extension is outside this read. |
STEP BY STEP
Filing steps
Read date: 10-09-2026
Research steps
- Use the current Wellpoint materials. UniCare in Massachusetts became Wellpoint effective 07-01-2024, and the current Total Choice handbook is effective 07-01-2026. https://www.wellpoint.com/mass/blog/unicare-is-becoming-wellpoint https://www.wellpoint.com/mass/health-plans/total-choice-plan
- Complete Medical Claim Form 107293MAMENWLP. Use a separate form for each patient and provider and complete every applicable patient, subscriber, service, accident, identifier, and amount field. https://www.wellpoint.com/content/dam/digital/wellpoint/documents/gic/mass/forms/107293MAMENWLP-Medical-Claim-FR-06-24-FILL-IN.pdf
- Add an itemized bill and proof of payment. Sign and date the certification. The form has no assignment-of-benefits field or box that expressly leaves payment with the member. https://www.wellpoint.com/content/dam/digital/wellpoint/documents/gic/mass/forms/107293MAMENWLP-Medical-Claim-FR-06-24-FILL-IN.pdf
- NO PORTAL UPLOAD: the current form and 2026-2027 Total Choice handbook publish only a nonportal claim route. Submit within two years after the service date. https://www.wellpoint.com/content/dam/digital/wellpoint/documents/gic/mass/member-handbook-totalchoice.pdf
- Check the claim through the Wellpoint member account using Check on my claims. NOT PUBLISHED: claim processing time and electronic submission confirmation. https://www.wellpoint.com/mass/members
Filing facts
- Portal upload: NO
- Portal: Wellpoint Medical Claim Form
- Portal path: NO: the current form and 2026-2027 Total Choice handbook publish only a nonportal submission route
- Mail address: Wellpoint, P.O. Box 4095, Woburn, MA 01888
- Fax: NOT PUBLISHED
- Attach: provider name and address; patient name; service provided; date of service; amount charged for each service; diagnosis code; procedure code; Tax ID; proof of payment
- File types: NOT PUBLISHED
- File size limit: NOT PUBLISHED
- Maximum files: NOT PUBLISHED
- One file or separate files: Separate form for each patient and provider, itemized bill, and proof of payment
- Confirmation: NOT PUBLISHED
- Status check: Wellpoint member account > Check on my claims
- Processing time: NOT PUBLISHED
- Member deadline: 2 years after the service date
- Deadline basis: This row maps the current 2026-2027 Total Choice GIC plan; PLUS and Community Choice benefits differ
- Mental health route: Wellpoint behavioral health; Carelon supports the behavioral network
Confirm the address, fax number or portal path on the insurer's own claims page before you send; read on 10-09-2026.
Read on 10-09-2026 from https://www.wellpoint.com/content/dam/digital/wellpoint/documents/gic/mass/forms/107293MAMENWLP-Medical-Claim-FR-06-24-FILL-IN.pdf. Confirm the address, fax number or portal path on the insurer's own claims page before you send.