Subscriber Reimbursement Medical Claim Form

  • Subscriber Reimbursement Medical Claim Form

     

    GENERAL INSTRUCTIONS:

    • Fill out the form completely. 
    • Claims must be filed within twelve (12) months from the date of service or they will be denied.
    • Attach proof of payment. Examples: cash receipt, credit card statement, copy of cancelled check. There is a spot to upload your documents on this form. 
    • Keep a copy of the itemized bill or receipt for your records.
    • Each form is only for one patient and one provider.
    • Do not submit a form if your physician or other health care professional is also filing a claim to GHC-SCW for the same service.
    • Services must be paid in full to qualify for reiumbursement.

  • PATIENT INFORMATION

  • Format: (000) 000-0000.

  • TYPE OF TREATMENT RECEIVED:

    • Check only one type and attached itemized statements.
    • Please use a seperate claim form for each different type of treatment.
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  • PROVIDER INFORMATION

  • Format: (000) 000-0000.

  • SERVICE INFORMATION

    (Ask Your Provider(s) to Help you Complete All Information)

  • SERVICE #1

  •  - -

  • SERVICE #2

  •  - -

  • SERVICE #3

  •  - -

  • SERVICE #4

  •  - -

  • SERVICE #5

  •  - -

  • If services are not in English, you are required to have documents translated, at your expense, prior to sending them to us. All inpatient claims must be submitted with translated chart notes.

  • CLINICAL DOCUMENTATION

    It is recommended that members submit clinical documentation for services outside of emergency care.

    DOCUMENTATION REQUIRED

    Group Health Cooperative of South Central Wisconsin requires proof that the services were rendered and that the member has paid for these services. For GHC-SCW to process your request, you must provide copies of the following:

    1. Provider statement or bill, showing name of provider and full itemized list of services or items provided.
    2. Customer receipt or statement, showing payments applied to your account in the form of cash receipt, credit card statement, or cancelled check front and back proving that the member has paid for the services rendered.
    3. If you have other primary insurance, a copy of their statement or EOB (explanation of benefits) is required.
    4. This form must be accompanied with all recepts and supporting documentation to be considered for
      reimbursement.
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  • MEMBER OR AUTHORIZED REPRESENTATIVE STATEMENT:

    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 Group Health Cooperative of South Central Wisconsin may request any additional information it deems necessary to verify that services were received and payment was made.

     

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  • Group Health Cooperative of South Central Wisconsin may request any additional information deemed necessary to verify services were received and payment was made.

    For questions or assistance, you may call our Member Services department at 800-605-4327. If all information has been correctly submitted and no additional documentation is required, you can expect your claim to be processed within 30 days of receipt by GHC-SCW. This is not a guarantee of payment. Actual payment for covered services will be paid at the appropriate level according to your plan benefit.

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