Please select an option below:

• View or download forms.

  CHIP Pharmacy Claim Form Termination of Coverage Request NE CHIP Application Form CHIP Claim Form Deductible Change Request Form Address Change Form Non-Smoker Change Request Form Health Savings Account (HSA) Request Form Authorization for Release of Protected Health Information Debit Authorization

• Request an application packet by mail.
  1. First Name(required)
  2. Middle Initial
  3. Last Name(required)
  4. Address 1(required)
  5. Address 2
  6. City(required)
  7. State(required)
  8. Zip(required)
  9. Daytime Phone
  10. Quantity 1 2 3 4 5 6 7 8 9 10 (required)

   

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• Please call me.
  1. Your Name(required)
  2. Phone #(required)
  3. Best Time No Preference Morning Afternoon Evening

   

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• Email a question to NECHIP.
  1. Email(valid email required)
  2. Message(required)

   

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• I am an Agent/Insurance Broker. Please send me more information.
  1. Your Name(required)
  2. Company(required)
  3. Address(required)
  4. City(required)
  5. State(required)
  6. Zip Code(required)
  7. Telephone(required)

  Quantities

  1. CHIP Enrollment Application 0 1 2 3 4 5 6 7 8 9 10
  2. CHIP Rate Schedule 0 1 2 3 4 5 6 7 8 9 10
  3. CHIP PPO Plan Brochure 0 1 2 3 4 5 6 7 8 9 10
  4. A Guide to Your Prescription Drug Benefits Brochure 0 1 2 3 4 5 6 7 8 9 10
  5. HSA Enrollment Form 0 1 2 3 4 5 6 7 8 9 10
  6. Courtesy Reply Envelopes 0 1 2 3 4 5 6 7 8 9 10
  7. Other - Please State
  8. Quantity 0 1 2 3 4 5 6 7 8 9 10

   

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NEBRASKA COMPREHENSIVE HEALTH INSURANCE POOL

Effective April 1, 2012 new applications and service questions should be directed to:

Coventry Health and Life Insurance Company
ATTN:  CHIP
PO Box 541210
Omaha, NE 68154
Toll Free:  855-247-5201   Fax:  866-799-9448
8:00 am to 5:00 pm Monday through Friday

Effective April 1, 2012 claims should be directed to:

Coventry Health and Life Insurance Company
PO Box 7705
London, KY 40742

Claims and service questions incurred prior to April 1, 2012, should be directed to:  

Blue Cross Blue Shield of Nebraska
ATTN: Kelly Richardson
PO Box 3248
Omaha, NE 68180-0001
Local: 402-982-8201