Helpful Tips For Claims Reimbursement

September 14, 2016

Here are some helpful tips to assist you in submitting claims for reimbursement from your new insurance carrier

Medical Services (Doctor, Hospital, Lab, X-Ray)

  • For PPO members: If you’ve already paid for services, complete the appropriate claim form (see reverse), attach your receipts and mail to the address on the claim form. Be sure to keep copies for your records.
  • For HMO members: If you’ve already paid for services, be sure the PCP and medical group you are assigned to are the same as those you received care from. If they are, complete the appropriate claim form (see reverse), attach your receipts and mail to the address on the claim form. Be sure to keep copies for your records. If not, contact your Group Administrator.

To be considered eligible for reimbursement for specialist visits, authorization is needed from your PCP within the assigned in-network medical group. If your specialist visit was pre-authorized, attach a copy of the authorization and your receipts to a completed claim form (see reverse) and mail to the address on the claim form. Be sure to keep copies for your records. If the visit was not pre-authorized contact your Group Administrator.

  • In order to complete the claim forms, you’ll need the group ID number as well as your member ID. It’s important to attach the record of payment, as it is required for reimbursement. Be sure to keep copies for your records.
  • If emergency services were rendered at a non-network facility, the new carrier must be notified immediately.

 

Prescriptions

  • If you had prescriptions filled while you were waiting for approval, complete the pharmacy claim form, attach your receipts and mail to the address on the claim form. For reimbursement, make sure the pharmacy receipt includes your name, the name of the drug, the dosage, the date and the cost. Be sure to keep copies for your records.
  • If you have a medication that requires prior authorization or other steps, please contact your Group Administrator. Note that mail order medications may require a new prescription and paperwork to be filed to establish the new distribution under your new carrier. Those forms are posted on the carrier website and are also available from your Group Administrator.

 

How to Follow Up

  • You can access claim status on the new carrier’s website or call the member services phone number on the back of your new ID card when it arrives.
  • If you incurred expenses since your new plan’s effective date and those services are applied towards your medical deductible, consider deductibles met (part/all) under your prior plan. Please confirm with your Group Administrator if you are eligible for deductible credits. If so, you’ll need to submit the most recent Explanation of Benefits (EOB) showing the dollars applied towards the member by name (each family