- Request for Reimbursement Form
- Co-Payment Maximum Claim Form
In order to process a request for reimbursement, the documents listed below must be submitted to our office within 90 days of the date of service. An incomplete request for reimbursement will not be accepted. NetCare will not request supporting documents from providers.
- You must submit a completed Request for Reimbursement Form for each provider. This form must be signed by the member, and the exact amount paid must be specified on the form.
- Original receipts must be submitted for each claim. (Cash register receipts will not be accepted.)
An insurance claim form completed by the physician’s office must accompany each receipt.
- Claim forms must include CPT & ICD-9 Codes.
- Statements from providers will not be accepted.
- Original receipts must be submitted for each prescription drug unit. (Cash register receipts will not be accepted). Receipts/labels must include the name of the drug dispensed and dosage.
- Medical notes or an insurance claim form completed by the physician’s office may be required based on the type of medication dispensed.
- Reimbursements for non-participating providers (providers outside the network) will be subject to Plan deductibles, UCR and the applicable percentage of the average wholesale price of the prescription drug. (Non-par prescription drug claims for Continental Airlines/Micronesia members will not be accepted).
- Original receipts must be submitted for each dental claim.
- An insurance claim form completed by the dentist’s office, treatment plan and tooth chart (if applicable) must accompany each receipt.
- Reimbursements for non-participating providers (providers outside the network) will be subject to UCR based on the benefit schedule of your Plan. (This also applies to emergency services)
Proof of payment required:
- Original receipts, cancelled checks or credit card statements.
All non-English claims must be translated into English.
- Translation must be specific and indicate exact treatment/service or prescription drug. State taxes, administrative fees, hotel rooms, etc. are not covered. For example, the translation ‘medicine’ is not acceptable, each item dispensed must be listed along with the dosage. Each item must be translated with the specific service detailed.
All of the above requirements must be met or the Request for Reimbursement will not be accepted and will be returned to the member. Once all documents are complete, reimbursement checks will be issued within 45 working days. Reimbursements from non-participating providers will first be applied to the member’s deductible, and are subject to UCR. (Please refer to your Plan Benefit Sheet for the non-participating provider deductible for your Plan). Once the deductible has been met, all subsequent reimbursements for non-participating providers will also be subject to UCR.
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