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InsuranceTPA Claim Form

The following are steps to submitting a claim yourself…

1. Please have your provider complete a HCFA–1500 form (non-hospital claims) for services you’ve paid for up front.

If the provider is unable to fill out claim form, please follow the instructions below.
(use downloadable form below and make copies as needed)


  • Here are the INSTRUCTIONS on how to fill out the ITPA HEALTH CARE CLAIM FORM.
  • Here is an EXAMPLE of a filled out ITPA HEALTH CARE CLAIM FORM.





If you have a Deductible Supplement Plan: 

You will need to fill out the form above and the form below which applies to you:

If you have a hospital claim we require that the hospital submit the UB 92 CLAIM FORM for processing.

SMART Accident Plus Logo

If you have an Accident Expense Plan:

You will need to download and fill out this form: ACCIDENT PLAN CLAIM FORM

QHP Supplemental Logo

If you have a QHP Supplemental Plan:

You will need to download and fill out this form: QHP SUPPLIMENTAL PLAN CLAIM FORM

2. Make a copy for your records and mail to:


14 N. Parker Drive
Janesville  WI 53545

If you have claims questions about a submitted claim, your eligibility or your benefits, please call (800) 279-2290 or [email protected]

The hours of operation at InsuranceTPA.com, Inc Customer Service are 8:30 am – 5:00 pm CST Monday-Friday. If a message is left with the Claims voicemail, your call will be returned within 24 hours or the next business day.

Thank you!
InsuranceTPA.com, Inc.
Claims Department