HOW TO COMPLETE YOUR OUT-OF-POCKET EXPENSE REIMBURSEMENT FORM
Please read this before you start to complete your Expense Reimbursement Form
To facilitate the processing of your out-of-pocket expense reimbursement claim, please send us a fully completed out of pocket expense reimbursement form for each medical provider that treated you and/or continues to treat you for the covered line of duty cancer for which the Line of Duty Cancer Initial Diagnosis Benefit has been paid,
(A). Provider. Identify the doctor or medical facility that rendered treatment for the line of duty cancer for which the Line of Duty Cancer Initial Diagnosis Benefit has been paid. ONLY ONE DOCTOR OR MEDICAL FACILITY SHOULD BE IDENTIFIED PER EACH OUT-OF-POCKET EXPENSE REIMBURSEMENT FORM.
(B). Date of Service. Enter date treatment was received for the line of duty cancer for which the Line of Duty Cancer Initial Diagnosis Benefit has been paid.
(C). Amount Billed. Enter the full amount charged for the date of service, identified in column B, related to treatment of the line of duty cancer for which the Line of Duty Cancer Initial Diagnosis Benefit has been paid.
(D). Amount applied to co-pay/co-insurance/deductible. Enter the amount of the co-pay/co-insurance and/or deductible found on the corresponding health insurance ***Explanation of Benefits (EOB) related to the date of service, identified in column B, for treatment of the line of duty cancer for which the Line of Duty Cancer Initial Diagnosis Benefit has been paid.
(E). Patient Paid. Enter the amount of the co-pay/co-insurance/deductible paid by the patient for the date of service, identified in column B, related to the line of duty cancer for which the Line of Duty Cancer Initial Diagnosis Benefit has been paid. THIS AMOUNT MUST CORRESPOND WITH THE MEDICAL BILL OR ITEMIZED STATEMENT AND HEALTH INSURANCE EOB.
(F). Payment Method with Proof Included. Enter how payment was made (i.e. check, cash, credit card) and include a copy of the paid receipt, front and back of the check or credit card statement as proof of payment related to the date of service, identified in column B, for treatment of the line of duty cancer for which the Line of Duty Cancer Initial Diagnosis Benefit has been paid.
(G). ***EOB. You must provide a copy of the health insurance ***EOB, medical bill or itemized statement specific to the date of service, identified in column B, related to treatment of the line of duty cancer for which the Line of Duty Cancer Initial Diagnosis Benefit has been paid. THIS INFOMRATION MUST INCLUDE A DESCRIPTION OF SERVICES RENDERED, ICD-10 CODES AND/OR CPT CODE.
ALL REQUIRED DOCUMENTS MUST BE ARRANGED & PRESENTED IN A CHRONOLOGIC, ORGANIZED MANNER TO ASSIST IN A TIMELY REVIEW OF THE REQUEST. FAILURE TO DO SO WILL RESULT IN A DELAY PROCESSING YOUR CLAIM.
Please make copies of the out-of-pocket expense reimbursement form as it is required with every request for reimbursement.
***Explanation of Benefits (EOB) - An explanation of benefits (EOB) is a statement from your health insurance company that explains the costs and coverage of medical services or treatments you received. It's not a bill, but rather a summary of the claim and how it was processed by your insurance. EOBs help you understand how your insurance plan works and how much you owe for covered services.