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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 images of your receipt(s) ready for upload.

 


Please do not use this form for prescription reimbursements.


Instead, download the 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
000-000-0000

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 provider through 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 provider here.

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 mandatory but may help us process your claim efficiently.

Provider/supplier address:

Provider/supplier contact details:

abc@abc.com

Your provider’s email address can often be found on a bill from your provider or by calling your provider directly.

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 19 MB.

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

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.

Submission date:

 

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 here.

 

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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