PEPM Billing Agreement | Meridian Health Services Network

Welcome to the Meridian HSN Medical and Supplemental Benefit Plan

We appreciate your organization signing up for our program. You have been directed to this web page to provide billing information for the PEPM payments. If you have any questions please call Meridian Health Services Network toll free at 1-800-994-1143.

Our website offers secure https hosting and has added software security programs. If you would prefer to not provide the billing information via the Internet, then call the Meridian Health Services Network corporate offices toll free at 1-800-994-1143 and we will gladly take your information over the phone.

Contact Information

Company This is the company that has signed up for the Meridian HSN Medical and Supplemental Benefits Plan and needs to set up PEPM Billing.
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Company Contact for the Program

Name
Title
Office Phone
Cell Phone
Email

Set up Monthly Payment Plan

Select how you want to pay - Credit Card or EFT
Your organization pays for the program on a monthly basis by credit card or Electronic Funds Transfer (ETF). Your organization submits the employee count list on the 15th of the month, and then your organization pays by the 18th of the month via credit card charge or ETF. If the 15th falls on a Saturday or Sunday, then we add one or two business days to the 15th and 18th.Option 1 - Pay by credit cardOption 2 - Pay by Electronic Funds Transfer

Payment Information for Credit Cards

Credit Card Type
If you wish to pay by credit card then fill out the information below. If you prefer to pay by Electronic Funds Transfer, then skip this section and fill out the EFT information below.VISAMastercardDISCOVER
Card Number
Name on the Card
Credit Card Expiration Date
CVC Security Code (3-digit code on the back of the card)

Payment Information for Electronic Funds Transfer

Financial Institution To pay by Electronic Funds Transfer, fill out the EFT information below.
Routing #
Account #

Electronic Signature

Your name, email and date are your electronic signature By the electronic signature below, your organization is authorizing Meridian Health Services Network to charge the credit card or set up an electronic bank transfer, in an amount equal to the total PEPM fees submitted through your monthly eligibility file, until such employer notifies Meridian Health Services Network in writing of intent to cancel. If the Employee Eligibility file is not received by Meridian Health Services Network and payment approved by the credit card or financial institution by due date, or the Meridian Health Services Network approved grace period; all employees will be deactivated at the end of the current month.
Your Name *
Title *
Email *
Today's Date *

Verification

Please enter any two digits *Example: 12
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