HOW TO COMPLETE THIS FORM

Transcription

1 HOW TO COMPLETE THIS FORM For your convenience, Sharp Health plan makes this reimbursement form available for your use. All requests for reimbursement received in writing shall be processed. 1. The Member or Authorized Person must provide the following information: Member Information, Physician Information, and Prescription Information Signature of the Member or Authorized Representative. Requests must be signed to process. Proof of Payment that shows your name must be attached, ( i.e., doctor s receipt, credit card Receipt, cancelled check front and back), etc.) Note: Please be sure to include all of the required information for your request to be processed without delay. In addition: If you are submitting claims for different providers you must complete a separate claim form for each provider you paid. If more than three claims are being submitted please use the Additional Claim Information Sheet Keep a copy of this form and all your receipts. Please submit originals with your claim for processing. The Pharmacy Information section should be completed by the pharmacy If you do not have receipts, claim submission requires the pharmacist s signature. Payment and related correspondence will be sent to the mailing address included on this form. Submit separate claim forms for each patient and pharmacy where you purchased medication. 2. When to submit the claim form: Claims should be submitted as soon as possible, preferably within: 365 days of the date of you purchased the prescription drug. If you don't submit a request within the 365 days, please include a written explanation to Sharp Health Plan showing good cause for the delay in filing. Please contact Customer Care at the number listed on the back of your ID card if you have any questions about completion of this form or if you wish to file an appeal. Appeals instructions are included in your Evidence of Coverage. 3. Situations in which you should ask the plan to pay our share of the cost of your covered services: This form should be used in certain instances, for example: If you are required to pay the full cost right away from a participating provider. If you believe you have paid more than you expected under the coverage of rules of the plan. If you received emergency or urgently needed medical care from a non-participating provider. 4. Payment of Claims When we receive your request for payment, we will let you know if we need additional information from you. We will consider your request and decide whether to pay it and how much we owe. If the services are approved we will pay you for our share of the cost minus any applicable deductible, coinsurance, copayments and/or out-of-network member cost sharing. If we decide that the medical care is not covered, or you did not follow all of the plan rules, we will not pay for our share of the cost. You will receive a written explanation of benefit(s) with the reason(s) for the denied payment and your rights to appeal that decision, as explained above. 5. Submission of the Completed Form: Return the completed requests and applicable receipt(s) to: MedImpact Healthcare Systems, Inc. P.O. Box San Diego, CA Fax: [email protected]

2 Member Reimbursement Form Prescription Drugs A. Member Information Member ID Number: Group No. (Employer Group Members only) Telephone No: ( ) - Last Name First MI Mailing Address: City: State/ Zip Code: Date of Birth: MM DD YYYY Relationship to Subscriber: Name of Health Plan/Insurance Self Spouse Dependent B. Physician Information: complete this section about the treating physician Provider Name: Telephone: ( ) - Street Address: City/State Physician NPI: Zip Code: C. Prescription Information: Complete this section to assist us in processing the claim. Please ask your provider for any information if it is not listed on your bill/receipt Compound Yes No - If yes, what line number(s) (submit the Compound Form):

3 D. Pharmacy Information: Populate the information below or affix the pharmacy label here: Pharmacy Name Telephone No: ( ) - Street Address City/State NPI Pharmacist Signature Date E. Reason Health Insurance Coverage Not Used: Select one: COB* Discount Card Used Non-Network Pharmacy Pharmacy could not process electronically Health Plan Information not available at time of purchase Insurance Card unavailable at time of purchase Part D vaccine administered in physician s office or clinic (please list cost of vaccine and administrative fees separately above) Emergency (please describe): *Coordination of Benefits: claims must be submitted with pharmacy receipt(s) showing copays paid and an EOB (explanation of benefits) from the primary carrier (a prescription history from the pharmacy showing primary insurance payment will suffice in lieu of an EOB) F. Notifications The law requires Sharp Health Plan include the following statement(s) to safeguard your rights and for your protection: Federal Law: The False Claims Act (FCA) imposes civil liability on persons who knowingly submit a false or fraudulent claim or engage in various types of misconduct involving federal government money or property. California Residents: Any person who knowingly (with intent to or assist with intent to) injure, defraud, or deceive an insurance company, files a claim containing false, incomplete or misleading information is guilty of a crime and may be subject to imprisonment, fines and/or denial of insurance benefits. Anyone committing the aforementioned act(s) is guilty of a felony and may be prosecuted under state law and subject to criminal penalties, civil fines and/or confinement to prison. Please be advised: Beneficiaries must use pharmacies participating in their health plan s network to access their prescription drug benefits. Benefits, Plan Formulary, Pharmacy Network, Premium and/or ment/coinsurance amounts are subject to change. Sharp Advantage is an HMO plan with a Medicare contract. Enrollment in our plan depends on contract renewal. To obtain either language translation services or this material in other format(s); call Sharp Health Plan Customer Care at: Customer Care hours of operation are. : Monday - Friday 8 am to 6 pm PST Acknowledgement: I certify that the information furnished in conjunction with this form is true and correct. I know it is a crime to fill out this form with facts I know are false. I understand that if I submit false receipts or fraudulently altered documents, I may be disenrolled from Sharp Health Plan and/or subject to civil or criminal penalties.. I understand that submission of a claim is not a guarantee of payment of the full amount. If the services are deemed covered services then the health plan will reimburse me their cost share minus any applicable deductible, coinsurance, copayments and/or out-of-network member cost sharing. I understand that the provider will not be paid for this/these service(s). I authorize the release of any information needed to review or process this request. Member/Authorized Representative** Signature **Authorized Representatives must complete an Authorized Representative form and submit it with this claim form or have one on record with the Sharp Health plan Date

4 Additional Claim Information Sheet (optional) Compound Yes No - If yes, what line number(s) (submit the Compound Form):

5 Compound Prescriptions Form Please Note: This form should be completed by the pharmacy dispensing the prescription. The member should receive this completed form (or a pharmacy provided Universal Claim Form), along with the original pharmacy prescription label or cash receipt, and the compounded medication. Make copies of all documents; the submitted originals will be kept on file with the health plan. All dollar amounts should be in US dollars. National Drug Code (11 Digits) Compound Prescriptions pharmacy use only Drug/Ingredient Charge Total Charge $