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REIMBURSEMENT REQUEST INSTRUCTIONS Claims can be mailed to: Meritain Health Company PO Box 30111 Lansing MI 48909 Or faxed to: (517) 381-6600 Complete the employee and expense information of the Reimbursement Request Form. Be sure to sign and date the bottom of the form. Please follow these instructions when requesting reimbursement: Health Care Account 1. Medical, Dental, Vision and Hearing Expenses If you have insurance, please attach the Explanation of Benefits (EOB) received from the carrier, or, if you have no insurance, the provider's itemized bill to a completed Reimbursement Request form and send it to Meritain. Be sure all documentation submitted includes the date of service, service that was performed, patient, amount charged and the amount covered by insurance. 2. Prescription Drug and Over the Counter Expenses Attach the pharmacy receipt to a completed Reimbursement Request Form and send it to Meritain. The Pharmacy receipt must include the patient's name, date of service, type of prescription and your co-pay. Over the counter expenses may be substantiated with a cash register receipt including the date of service and the name of the product purchased. If the receipt does not include the name of the OTC expense, attach a copy of the box top including the name and the price of the expense matching the receipt. Unreasonable stockpiling will not be eligible. Unreasonable stockpiling is the purchase of an item or items in excess of your immediate need.

Payments on account, cash register receipts (with the exception of over the counter items), credit card receipts and cancelled check copies alone are not sufficient documentation. Estimated and/or anticipated insurance amounts are not considered proof of insurance payments, therefore, balances based on estimated or anticipated insurance are not eligible.

Dependent Care Account Attach your proof of payment (receipt, cancelled check, etc.) to a completed Reimbursement Request Form and send it to Meritain. Be sure to include the dates of service and provider ID on the Reimbursement Request Form. Field trips, supplies, food, and education are not eligible expenses.

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