Forms

• Appeals Claim Form
• Medical Claim Form (can be used for In-Network & Out of Network Claims)
• Flu Vaccine Reimbursement Form
• Shingles Vaccine Reimbursement Form
• Coordination of Benefits Form

Transparency in Coverage

The Transparency in Coverage rule requires health plans and issuers to publicly disclose pricing information via machine-readable files (MRF).

Jefferson is responsible for the accuracy of the Machine-Readable Files.