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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 Peach State Health Plan has on record (To view your address of record, please log on to [AmbetterHealth.com/en/ga or call Member Services at](AmbetterHealth.com/en/ga or call Member Services at) 1-877-687-1180 (TTY 1-877-941-9231) .\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 Me","cbCaicWh6SGv44z6","https://ap.wps.com/l/cbCaicWh6SGv44z6","pdf",261546,"English","# Instructions\n# Subscriber Information\n# Patient Information\n# Claim Information\n## Diagnosis Codes\n## Procedure Codes\n# Member Signature, Attestation, and Checklist\n# Submission Address","[{\"question\":\"申请报销需要提交哪些材料？\",\"answer\":\"需提交已完成并签署的报销表、服务已发生的证明、逐项付款凭证，以及逐项列出需报销的服务或零售项目。\"},{\"question\":\"提交申请的截止时间和处理时长是多久？\",\"answer\":\"通常需在服务日期起一年内提交，完整申请多在30天内处理，未完整或不在美国提供的服务可能更久；清单中也提到大多数完整申请在45天内处理。\"},{\"question\":\"报销款将寄送到哪里？\",\"answer\":\"报销款将寄送给计划参保人（Plan subscriber），使用Ambetter from Peach State Health Plan记录中的地址。\"}]","2025-2026 Member Reimbursement Medical Claim Form - Submit One Form Per Family Member Per Provider | PDF",1789798612]