[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-301964-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-301964-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","2025-2026-member-reimbursement-medical-claim-form-help-sheet-faqs","2025-2026 Member Reimbursement Medical Claim Form - Help Sheet / FAQs","","2025-2026 Member Reimbursement Medical Claim Form用于成员仅提交医疗费用报销申请。表单要求为每位家庭成员、每个提供方填写一份，并由医疗服务提供方协助提供诊断与程序代码等信息。申请需在服务日期后一年内提交完整签署表、服务证明及分项付款与服务清单；多数完整申请约30天处理，材料不全或美国境外服务可能延长。报销款将寄送至计划登记的会员地址，并要求保留收据与签署声明。",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/2025-2026-member-reimbursement-medical-claim-form-help-sheet-faqs/301964/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/2025-2026-member-reimbursement-medical-claim-form-help-sheet-faqs/301964.png","ImageObject",442,249,{"name":42,"@type":43},"Terk","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-23","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":26},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"How long do I have to submit a medical reimbursement request?","Question",{"text":62,"@type":63},"Submit the completed request within one year from the date of service. The one-year requirement may be waived if you or your covered dependent member had no legal capacity to submit proof during that year.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"What documents must be included to request reimbursement?",{"text":67,"@type":63},"Include the completed and signed reimbursement form, proof of services rendered, itemized proof of payment for the requested services, and an itemized list of services or retail items for reimbursement review.",{"name":69,"@type":60,"acceptedAnswer":70},"Where will the reimbursement payment be sent?",{"text":71,"@type":63},"Reimbursement is sent to the Plan subscriber at the address Ambetter from Superior HealthPlan has on record.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},301964,1790193805,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":26,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":22},1099525198933,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","2025-2026 MEMBER REIMBURSEMENT MEDICAL CLAIM FORM  \nFor Medical claims only-please complete one form per family member per provider  \n\n| Instructions |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| 1. You will need your health care provider to assist and supply information in completing this form, including the procedure code(s) and diagnosis code(s) . It is recommended that you bring it with you to your appointment. Please also refer to the Help Sheet for additional information.\u003Cbr>2. To request reimbursement, please submit the following to the address listed at the bottom of this form within one year from date of service† (any missing information may result in delay or denial of the request):\u003Cbr>a. This completed and signed reimbursement form b. Proof of services rendered c. Include itemized proof of payment for the services being requested for reimbursement d. Include itemized list of services or retail items for reimbursement review.\u003Cbr>3. Most completed reimbursement requests are processed within 30 days. Incomplete requests and requests for services that were rendered outside of the United States may take longer.\u003Cbr>4. Reimbursement will be sent to the Plan subscriber (see Help Sheet for definition) at the address Ambetter from Superior HealthPlan has on record (To view your address of record, please log on to [AmbetterHealth.com/en/tx or](AmbetterHealth.com/en/tx or) call Member Services at 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) .\u003Cbr>5. Retain a copy of all receipts and documentation for your records. |  |  |  |  |  |  |  |  |  |  |  |\n| Subscriber Information |  |  |  |  |  |  |  |  |  |  |  |\n| Last Name: |  |  |  | First Name: |  |  |  |  | Middle Initial: |  |  |\n| Patient information |  |  |  |  |  |  |  |  |  |  |  |\n| Patient’s Ambetter Member ID\\#: |  | Last Name: |  |  |  |  | First Name: |  |  | Middle Initial: |  |\n| Date of Birth (MM/DD/YYYY) : |  |  |  |  |  | Mailing Address: |  |  |  |  |  |\n| Telephone Number: |  |  | Patient Email Address: |  |  |  |  | Does Patient have additional insurance?\u003Cbr>☐Yes ☐No |  | Did other Insurance make a payment:☐Yes ☐No (If yes, include plan’s EOB) |  |\n| Other Insurance Company Name: |  |  |  | Other Insurance Company Phone Number: |  |  |  |  | Other Insurance Policy Number: |  |  |\n| Claim Information\u003Cbr>(This section must be completed, and you will need your health care provider to assist in completing this section) |  |  |  |  |  |  |  |  |  |  |  |\n| Healthcare Provider’s Name: |  | Healthcare Provider’s NPI Number: |  |  |  |  | Healthcare Provider’s Federal Tax ID \\#: |  |  | Healthcare Provider’s Telephone Number: |  |\n| Organization/ Group Name: |  | Organization/ Group NPI Number: |  |  |  |  | Organization/ Group Telephone Number: |  |  | Setting where treatment was received: |  |\n| Healthcare Provider’s Address: |  |  |  |  |  |  |  |  |  | Were services received outside of the U. S.?\u003Cbr>☐Yes ☐No |  |\n| Detailed explanation of illness/injury, including date(s) of injury/illness and explanation if a non-contracted provider was utilized: |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |\n| Diagnosis Codes | Diagnosis Description (e. g. , flu, broken leg, manicdepressive disorder, asthma) |  |  | Date(s) of Service |  |  |  | Procedure Codes\u003Cbr>(for each service provided) * | Procedure Descriptions (e.g., x-ray, office visit, lab work, leg cast, etc. ) * |  | Amount Paid |\n| . |  |  |  | / | / |  |  |  |  |  | $ |\n| . |  |  |  | / | / |  |  |  |  |  | $ |\n| . |  |  |  | / | / |  |  |  |  |  | $ |\n| . |  |  |  | / | / |  |  |  |  |  | $ |\n| No more than 30 days/ one month of reimbursement requests per form.\u003Cbr>* Procedure and diagnosis codes may not be available for retail or foreign provider claims.\u003Cbr>† One year requirement will be waived if you or your covered dependent member had no legal capacity to submit such proof during that year.\u003Cbr>Ambetter Member signature i","cbCaipjRE1M6I5pp","https://ap.wps.com/l/cbCaipjRE1M6I5pp","pdf",265781,"English","# Instructions\n## Submission requirements\n## Processing timelines\n## Address of record and payment\n# Subscriber information\n# Patient information\n# Claim information\n## Provider details\n## Treatment setting and explanations\n# Diagnosis and procedure codes\n# Signature and attestations\n# Checklist and required documents\n# Submission address\n# Help Sheet / FAQs","[{\"question\":\"How long do I have to submit a medical reimbursement request?\",\"answer\":\"Submit the completed request within one year from the date of service. The one-year requirement may be waived if you or your covered dependent member had no legal capacity to submit proof during that year.\"},{\"question\":\"What documents must be included to request reimbursement?\",\"answer\":\"Include the completed and signed reimbursement form, proof of services rendered, itemized proof of payment for the requested services, and an itemized list of services or retail items for reimbursement review.\"},{\"question\":\"Where will the reimbursement payment be sent?\",\"answer\":\"Reimbursement is sent to the Plan subscriber at the address Ambetter from Superior HealthPlan has on record.\"}]","2025-2026 Member Reimbursement Medical Claim Form - Help Sheet / FAQs | PDF",1789787516]