Claims Inquiries

All requests for assistance are processed Monday through Thursday, 9AM - 5PM and Friday 9AM - 3PM Central Time. Whenever possible, IMA will respond to all requests within one business day.

Participant: Employer & Group #

Employer Name		Group Number

Participant: Name, Date of Birth and/or SS#

First Name	MI	Last Name	Date of Birth (MM/DD/YYYY)		Social Security #
			//	AND/OR	--

Patient (if other than Participant)

First Name	MI	Last Name	Date of Birth (MM/DD/YYYY)		Social Security #
			//	AND/OR	--

Claim Number AND/OR Provider & Date of Service

Please provide the claim number (if known). Otherwise, you must supply at least the provider name and date of service in order to identify a specific claim.
Claim # (if known)		Provider Name	Date of Service (MM/DD/YYYY)
	AND/OR		//

Question(s), Notes or Comments

Enter your question(s), notes or comments in the space below:

Preferred Method of Reply (Email, Phone)

	Email (agent will respond via email)
	Email:
	Daytime Phone Number (please select the best contact time) (Mon-Thurs: 9am-5pm; Fri: 9am-3pm Central)
	Phone #: () - 9am-5pm9am-10am10am-11am10am-11am11am-12pm12pm-1pm1pm-2pm2pm-3pm3pm-4pm4pm-5pm

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