MBA Programs

MBA handles a variety of insurance plans, including Dental, Medical, and Vision. Below is a list of all the insurance plans administered by MBA.

Medical Claim Forms - HCFA & UB04 

A Medical Claim Form is used by members or providers to request reimbursement for covered medical services received. It includes details about the patient, provider, treatment, and payment to support claims processing.

Timely Filing Limit: 12 months from DOS  

ADA (American Dental Association) Dental Claim Form  

The ADA Dental Claim Form is the standardized form used by dental providers to submit claims for dental treatments and services. It includes detailed information about the patient, provider, procedures performed, and fees charged to ensure accurate and efficient claims processing and reimbursement.

Timely Filing Limit: 15 months from DOS
Mailing Address: PO Box 35249 Phoenix, AZ 85021-9998 ELT PAYER ID: MBAAZ  

HIPAA RELEASE FORM

This form is used to confirm a Member’s permission that Merchants Benefit Administration (MBA, Inc.) may discuss or disclose Protected Health Information (PHI) to a particular person who acts as the Member’s Personal Representative. Use of the PHI is strictly limited to that purpose. This authorization does not allow for a Member’s Personal Representative to make changes to the Member’s account. 

MEMBER REIMBURSEMENT REQUEST 

A Member Reimbursement Request is submitted when a member seeks repayment for out-of-pocket expenses they incurred for eligible healthcare services. The request typically includes receipts, proof of payment, and supporting medical documentation, and must meet plan-specific requirements for approval. 

Multiflex Dental Coverage Cancellation Request Form 

This form is used by members to request the cancellation of their Multiflex Dental insurance coverage. It must be completed in full and submitted as per the instructions to ensure timely processing of the cancellation. 

MFD Member Address Change  Form 

This form is used by Multiflex Dental (MFD) members to update their mailing or residential address. Keeping address information current ensures accurate delivery of plan materials and correspondence. 

Seniors Choice Group Address Change Form  

This form is used to update the address on file for a Seniors Choice group account. Submitting accurate address information ensures continued delivery of important plan communications and documents. 

Seniors Choice Coverage – Member Cancellation Request Form   

This form is used by members to request the cancellation of their Seniors Choice coverage. To ensure timely processing, all required fields must be completed and the form submitted according to the provided instructions.