Affinity Health Plan

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  • Non-Participating Provider Verification Form

    In order to process your most recent authorization and/or claim, please complete and fax the non-participating provider verification form to Affinity at 1-718-536-3315 within three (3) days of receipt of your authorization. In addition, please attach a W9 form.

    If your claims were rejected by Affinity Health Plan via Emdeon with the Affinity Code of “86” (please go to Claims Status Codes link for details) your information can then be loaded into our systems within 10 business days of receipt of the verification form. After submitting this form to Affinity, you may resubmit your claims electronically after 10 business days.