Submit A Reimbursement Request

How Do I File A Reimbursement Request?

Each reimbursement is based on the provider and date of service, similar to health insurance. In order to efficiently and quickly process your reimbursement, each date of service must be entered as its own reimbursement request. Each reimbursement submission must contain the required documentation to be processed. As an example, if you saw your primary care doctor on March 3rd and again on April 8th, you need to submit two reimbursements. Hospital stays that span multiple days do not require separate submissions. If you submit multiple dates of service in the same submission, your submission may be declined and require a corrected submission.


Keep in mind:

  • We will only reimburse for eligible medical needs that are submitted within 6 months of the date of service.
  • Reimbursement may take up to an average of 30–45 days to process once all required information has been received.
  • If your medical needs arise from an accident, injury or emergency room visit, we may request a Needs Processing Form and/or associated medical records to determine eligibility.

What Steps Need To Be Completed?

As the Patient we need you to:

  1. Provider Documentation: Obtain an itemized statement or SuperBill from your provider.
  2. Proof of Payment: A receipt or other proof of payment to the provider.
  3. Submit your Reimbursement form: Please have all your documentation ready. PDF files are preferred.

We will then:

  1. Review the reimbursement submission to ensure you’ve provided all information.
  2. Review your submission compared to the membership guidelines for your plan.
  3. If your reimbursement is eligible per your membership plan, we will process your submission and send you a check once your applicable MRA’s have been met!

Provider Documentation

To process your reimbursement we need the following information from your provider. All of this information should be available on an itemized statement or what is called a SuperBill.

  • Provider Name, Address, and Phone Number
  • Date of Service
  • Diagnosis Code (ICD-10)
  • Procedure Codes (CPT, HCPCs, and Rev Codes)

Proof Of Payment

A receipt from the provider is best. Other examples include:

  • a healthcare provider statement with the amount you paid displayed
  • a credit card receipt or statement
  • a bank statement

Submit Your Reimbursement From

  1. Make sure you have
    1. All applicable files
    2. Your member ID number
    3. The patients First Name, Last Name, and Birthdate
  2. Click HERE to start your reimbursement request