Fillable Printable Member Reimbursement Medical Claim Form

Member Reimbursement Medical Claim Form

MeMber reiMburseMent Medical claiM ForM

(please complete one form per family member per provider)

Please submit this form and all documentation to:

tuFts HealtH Plan • MeMber reiMburseMent claiMs, P.o. box 9191 • WatertoWn, Ma 02471-9191

instructions

1. You will need your health care provider to assist and supply information in completing this form, including the procedure code(s) and diagnosis code(s). It is recommended that

you bring it with you to your appointment. Please also refer to the Help Sheet for additional information.

2. To request reimbursement, please submit the following to the address listed at the bottom of this form (any missing information may result in delay or denial of the request):

a. This completed and signed reimbursement form b. Proof of services rendered c. Proof of payment for the services being requested for reimbursement

3. Most completed reimbursement requests are processed within 30 days. Incomplete requests and requests for services that were rendered outside of the United States may take

longer.

4. Reimbursement will be sent to the Plan subscriber (see Help Sheet for definition) at the address Tufts Health Plan has on record (To view your address of record, please log on to

tuftshealthplan.com or call Member Services at the number listed on the back of your ID card.)

5. If you are seeking reimbursement for a class such as childbirth, the class must be completed, a certificate of completion must be included, and the class must be paid in full prior

to the reimbursement request. For lactation classes, please include the newborn’s date of birth in the box next to the parent’s date of birth.

6. Retain a copy of all receipts and documentation for your records.

subscriber information

Subscriber Last Name First Name Middle Initial

Patient information

Patient’s Tufts Health Plan ID# Patient’s Email Address

Patient’s Last Name First Name Middle Initial

Date of Birth (MM/DD/YYYY) Telephone Number

– –

claim information

(this section must be completed and you will need your health care provider to assist in completing this section.)

Health Care Provider’s Name Setting where treatment was received Telephone Number

– –

License# and State of License

Address

Were services received outside of the U.S.?

No, proceed to next question

Yes, answer the following questions:

In what country was the patient seen?

In what language was the bill written?

In what currency was the bill paid?

Diagnosis Codes Diagnosis Description (e.g., ﬂu,

broken leg, manic-depressive

disorder, asthma)

Date(s) of Service Procedure Codes

(for each service

provided)

Procedure Descriptions

(e.g., x-ray, ofﬁce visit, lab

work, leg cast, etc.)

Amount Paid

/ / $

Total amount paid

Patient signature is required

I attest that the above information is true and accurate and that the services were received and paid for in the amount requested as indicated above. I acknowledge that if any

information on this form is misleading or fraudulent my coverage may be cancelled and I may be subject to criminal and/or civil penalties for false health care claims. I understand

that reimbursement payment will be made to the Plan subscriber and will contain information about the service (e.g., provider name, date, description of service). I also understand

that Tufts Health Plan may request any additional information it deems necessary to verify that services were received and payment was made.

Printed name Signature Date

checklist

I have completed and signed this form in its entirety.

I have enclosed proof of payment (see the help sheet for an example

of proof of payment).

I have enclosed proof of service (see the help sheet for an example of proof of

service).

I have included the certiﬁcate of completion for covered health

education classes and the newborn’s date of birth if needed.

I understand that most completed reimbursement requests are processed within

30 days. Incomplete requests and requests for services rendered outside of the

United States may take longer.

MeMber reiMburseMent Medical claiM ForM HelP sHeet

#18143-08/12

This example demonstrates both

proof of payment and proof of service

ProoF oF serVice and ProoF oF PayMent exaMPles

Field naMe descriPtion

Subscriber Information

Subscriber is the person:

• who enrolls in Tufts Health Plan and signs the membership application form on behalf of him/

herself and any dependents.

• in whose name the premium is paid.

Patient’s Tufts Health Plan ID# ID# with suffix, found on the front of the Tufts Health Plan ID card.

Patient’s Name Last and First names and Middle Initial of patient who received services.

Patient’s Date of Birth

Date of birth: month (2 digits), day (2 digits), year (4 digits). Include newborn’s date of birth in the

same box as the parent’s for lactation classes.

Provider’s Name, Address, Telephone Number,

License#, and State of License

A provider includes, but is not limited to, hospitals, physicians, optometrists, psychiatrists, licensed

clinical social workers, Durable Medical Equipment suppliers, and pharmacies (for covered items

that are not submitted to your pharmacy vendor).

In what setting did the patient receive treatment?

Such as office, emergency room, outpatient hospital (for X-rays, tests), inpatient hospital, clinic,

medical supply store.

If services were rendered outside of the U.S.

If applicable, indicate in what country services were provided, in what language (if not English)

the bill and proof of payment were written, and in what currency the bill was paid.

Diagnosis: What was the patient seen for?

Provide a diagnosis code and detailed description of illness or injury. (e.g., flu, broken leg, manic-

depressive disorder, asthma)

Date(s) of Service The date(s) the services were provided to the patient.

Procedures, Services, or Supplies Provided Provide a procedure code and detailed description. (e.g., x-ray, office visit, lab work, leg cast, etc.)

Total Amount Paid Total amount for which you are requesting reimbursement.

Proof of Service(s)

A document that demonstrates the service was actually rendered, listing date(s) of service,

service(s) provided, and dollar amounts paid.

Proof of Payment

A document that demonstrates payment made by the member was received by the provider of

service. Examples include: The front and back of the cancelled check written to the provider or

the bank encoded front of the check written to the provider; a credit card statement or receipt;

a statement from the provider, on the provider’s letterhead with authorized signature, indicating

payment was made; a receipt for purchased items, with the provider’s name and address

preprinted on the receipt, with items listed and amount paid.

This example demonstrates proof of payment