Edit, Download, and Sign the Fidelis Care Member Medical Reimbursement Claim Form
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How do I fill this out?
To fill out this form, begin by printing your personal information including name and Member ID. Next, describe the reason for your reimbursement request and the related medical service details. Finally, tally up the total reimbursement amount and ensure all required documents are included.
How to fill out the Fidelis Care Member Medical Reimbursement Claim Form?
1
Print your name and Member ID.
2
Provide your mailing address and telephone number.
3
Detail the services rendered, including dates and provider names.
4
Attach itemized bills and proof of payment.
5
Mail the completed form to the specified address.
Who needs the Fidelis Care Member Medical Reimbursement Claim Form?
1
Individuals seeking reimbursement for medical expenses.
2
Patients who have paid out-of-pocket for services.
3
Members of Fidelis Care who require financial compensation.
4
Families managing multiple medical expenses for dependents.
5
Anyone needing to follow up on unpaid medical bills.
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Select the edit option from the toolbar.
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Download your final version for submission.
What are the instructions for submitting this form?
To submit this form, complete all required fields and ensure that all necessary documentation is attached. Mail the completed form and accompanying documents to Wellcare By Fidelis Care Member Reimbursement Department at P.O. Box 10700, Farmington, MO 63640-5003. For any inquiries or assistance, please contact Member Services at 1-800-247-1447.
What are the important dates for this form in 2024 and 2025?
Important dates for this form include submission deadlines related to your health plan's policy. Ensure you are aware of your plan's specific deadlines and guidelines for reimbursement requests. Regularly check updates from Wellcare By Fidelis Care regarding policy changes.
What is the purpose of this form?
The primary purpose of the Medical Reimbursement Claim Form is to facilitate prompt compensation for medical expenses that members have paid out-of-pocket. This form ensures that all claims are documented and processed according to Wellcare By Fidelis Care's policies. It is a vital tool for members to reclaim funds spent on medical services that qualify under their health insurance plan.
Tell me about this form and its components and fields line-by-line.
- 1. Member Name: The name of the member submitting the claim.
- 2. Member ID: The unique identifier for the member.
- 3. Address: The mailing address of the member.
- 4. Telephone: Member's contact number for any inquiries.
- 5. City: City of residence.
- 6. State: State of residence.
- 7. ZIP Code: Postal code of the member's residence.
- 8. Date of Service: The date when the medical service was rendered.
- 9. Provider Name: Name of the doctor or facility providing services.
- 10. Description of Service: Brief description of the medical service received.
- 11. Amount Requested: Amount to be reimbursed for the services rendered.
- 12. Total Amount of Reimbursement Request: Total sum of all individual service requests.
What happens if I fail to submit this form?
Failing to submit the form can lead to delayed reimbursement or outright denial of your claim. It's important to ensure the form is filled out completely and accurately to avoid complications.
- Delayed Processing: Your claim may take longer to process, delaying any possible reimbursement.
- Claim Denial: Incomplete forms or missing documentation can lead to denial of your claim.
- Inaccurate Information: Submitting incorrect information could result in complications with your reimbursement.
How do I know when to use this form?
- 1. Reimbursement for Doctor Visits: Use this form to claim back costs incurred during doctor visits.
- 2. Hospital Services: Applicable for services received at hospitals, both inpatient and outpatient.
- 3. Laboratory Tests: For costs associated with medical laboratory tests.
- 4. Surgical Procedures: Necessary for surgeries performed and related expenses.
- 5. Therapeutic Services: For reclaims associated with physical therapy or similar treatments.
Frequently Asked Questions
How do I request reimbursement?
To request reimbursement, complete the claim form with all required details and submit it to the specified address.
What documents do I need to attach?
You need to attach itemized bills along with proof of payment documentation.
How long does the reimbursement process take?
Reimbursement requests are processed within 60 days of receipt.
Can I submit my claim electronically?
Currently, claims need to be printed and mailed; electronic submission is not available.
What if I made a mistake on my claim form?
If you made a mistake, simply complete a new form with the corrected information.
Is there a specific coverage amount for reimbursement?
Reimbursement is based on eligibility and the specific services rendered, as indicated in your plan.
Can I track my reimbursement request?
You may contact Member Services for updates on the status of your reimbursement claim.
What should I do if my claim is denied?
If your claim is denied, you can contact Member Services to understand the reasons and seek assistance.
Do I need my doctor to sign the form?
No, your doctor's signature is not required, but their information must be included on the form.
Where do I send the completed claim form?
Mail the completed form to the Wellcare By Fidelis Care Member Reimbursement Department.
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