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Reimbursement request


Please enter your member ID and date of birth to get started.

This form is supported on desktop and mobile devices. It takes approximately 10 minutes to complete. In addition to your member ID, you'll need a clear image of your receipt(s) ready for upload.

 

Please do not use this form for fitness or prescription reimbursements.

 

For fitness reimbursements, download this form: (English | Español)

 

For prescription reimbursements, download this form: (English | Español)

 

All fields are required.

Find your member ID number on your ID card, welcome letter or any Explanation of Benefits statement you received from us. Get help locating your member ID.

MM/DD/YYYY

Reimbursement form


Fill out this form if you paid a provider for covered medical, dental, vision, hearing or vaccination services and want to request reimbursement.

 

Filing instructions:

  • You may see any licensed provider who accepts Medicare patients in the U.S., and you must provide the name of the individual practitioner who performed the service.
  • Please submit the form within 365 days of receiving the service or item. 
  • If we approve your request, it can take up to 30 days to send payment once we have all the required information. 
  • Processing may be delayed if your request is incomplete. 
 

Your information


All fields marked with * are required.

Find your member ID number on your ID card, welcome letter or any Explanation of Benefits statement you received from us. Get help locating your member ID.

MM/DD/YYYY

Address:

Contact details:

abc@abc.com

Provide your email address to receive status updates about your form submission.

000-000-0000

Please provide the best number to reach you. We will only contact you for updates about your reimbursement request.

Who provided your service or products?


All fields marked with * are required.

A National Provider Identifier (NPI) is a unique 10-digit number that identifies your doctor though the health care industry. Providing this number is not required, however it helps us process your request more efficiently. You can get this number from your itemized bill, or by looking up your doctor with our provider search tool.

The federal Taxpayer Identification Number (TIN) identifies the physician, practice or supplier to whom payment is made for the service. Your provider's TIN can be found on a bill or by calling your provider directly. Providing this number is not required, however it helps us process your request more efficiently.

Provider/supplier address:

Provider/supplier contact details:

000-000-0000

What you received


The information entered in this section must match your itemized bill.
All fields marked with * are required.

MM/DD/YYYY

List and briefly describe any services or products you received that are relevant for this reimbursement request. Examples include but are not limited to: dental cleanings, dental fillings, eye exams, or eyeglasses. If you have the procedure code available, please include it. Procedure codes are usually found on the bill you received from your provider. Providing the procedure code is not required, but can help us process your request more efficiently.

Upload receipt


Attach an itemized receipt showing your provider's name. You can upload a scanned copy or a picture taken on your phone.

Instructions:
 

  • Make sure the file name doesn't contain any spaces and includes only letters, numbers, hyphens (-) and underscores (_). No other special characters are allowed.
  • Examples of acceptable file names: FileName.pdf, File_Name2.jpg, File_name-3.png.
  • Use PDF, JPG or PNG file format.
  • Confirm that the file is not password protected.
  • Attach up to 5 files totaling no more than 19MB.

Drag and drop one file at a time here or browse to upload.

  • Make your receipt as flat and wrinkle-free as possible.
  • Take the picture in a well-lit area or turn on your flash.
  • Keep the camera still until the picture is fully processed (this can take a few seconds, depending on your phone or camera).
  • Put your receipt on a flat, non-reflective surface and hold the camera directly above it.
  • Make sure the camera is close enough that the text is readable and not blurry. If necessary, take a picture of each section of the receipt up close.

Acknowledgement

  • In order to process your claim, we may need to disclose the information on the form to other persons and entities.
  • Submitting a claim is not a guarantee of payment, or payment in the full amount.
  • If the service(s) or item(s) you received are covered, the health plan will reimburse you up to the benefit amount minus any applicable deductibles, coinsurance or copayments.
  • It is a crime to fill out this form with information you know is false.
 

Disclaimers


Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

 

See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.

Thank you! Your request for reimbursement has been sent

Confirmation number: [confirmation-number]

 

Submission date: [submission-date]

Provider name: [provider-name]

Date of service: [date-of-service]

 

Here's what happens next:

 

  • We will start processing your request soon.
  • If you provided your email address, we will send you a confirmation email and status updates about your reimbursement request.
  • It may take up to 30 days from the time we receive all the information until we complete our review.
  • When your request is complete, details can be viewed on your secure member website.

     

Submission of a claim is not a guarantee of payment, or payment in the full amount. If the services are deemed covered services, then the health plan will reimburse you up to the benefit amount minus any applicable deductibles, coinsurance, or copayments.

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