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Reimbursement form


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

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.

Do not use this form for prescription reimbursements


Instead, download the form (English | Español) or call the Member Services number on your member ID card for a prescription drug claim form.

 

Filing instructions:
 

  • Please submit the form within 365 days of receiving the service or item.
  • If your request is incomplete, we will communicate with you on your monthly Explanation of Benefits statement. This will delay processing.
  • 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. If we approve your request, it can take up to 45 days to send payment once we have all the required information.
 

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.

National Provider Identifier (NPI) is a 10-digit number used to identify all providers. Your provider's NPI can be found on your bill, by calling your provider directly or by finding them on 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 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

Tell us about the service or supplies for which you are requesting reimbursement. Examples include: Dental cleaning, dental filling, eye exams, or glasses.

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:

 

  • Use PDF, JPG or PNG file format.
  • Confirm that the file is not password protected.
  • Make sure the file name only includes letters, numbers, hyphens (-) and underscores (_).
  • Attach up to 5 files totaling no more than 19MB.

Examples of acceptable file names: FileName.pdf, File_Name2.jpg, File_name-3.png.

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

Acknowledgement
 

  • It is a crime to fill out this form with information you know is false.
  • 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.
  • In order to process your claim, we may need to disclose the information on the form to other persons and entities.
 

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.

Your form has been sent

Submission date:

If your request is incomplete, we will communicate with you on your monthly Explanation of Benefits statement and this will delay processing. If we approve your request, it can take up to 45 days to send payment once we have all the required information.

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