How to File a Claim

You can print a claim form from this website. All expenses must be itemized on the claim form, along with a signature and date. You can include a separate sheet of paper to itemize your expenses if there is not enough space on the claim form. "See attached expenses" is not acceptable and will be returned. Any claim form not filled out completely and legibly will be denied and/or returned.

All expenses must include the following supporting documentation:

Date of Service

Type of Service performed

Provider's Name

Amount of Charges

For Prescription expenses, the Rx # or name of prescription must be included with all of the above.

For Dependent Care expenses, the provider's Tax ID or social security number must be included with all of the above.

Acceptable types of Supporting Documentation Include:

Itemized billing statement from provider with dates of service and types of service performed.
Explanation of Benefit from your insurance company
Receipt from provider with all information above

Unacceptable types of Supporting Documentation include:

Canceled checks or copies of checks
Credit card receipts or billing statements
Balance forward or previous balance statements
Estimates of services to be incurred.

Dates of services must take place during your Plan Year. Eligible expenses will be reimbursed based on the date the service was incurred, not the date when the service was billed or paid for.
Expenses incurred prior to your effective date, or after termination in the plan are not eligible for reimbursement.
You will have a 90-day grace period (runout) after the end of the Plan Year to request reimbursement of services incurred during the Plan Year. Example: If your Plan year is January 1st through December 31st, you have until the last day of March the following year to mail, fax or hand deliver your claim. Any claim not postmarked or otherwise not received by the last day of the runout will be denied. The appeal process is not a remedy for late claims.
Your claim will be processed within 3-5 business days, and a check or direct deposit statement will be mailed to your home. All reimbursements will be issued to the member. We cannot issue checks to providers.