6696R1 Pg 2 4.1.04 790.3249 6696 Claimreim
User Manual: 790.3249
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OxfordFlex SM Claim Reimbursement Form (OxfordFlex SM Healthcare /OxfordFlex SM Dependent Care ) Attn: OxfordFlex Claims Department, P.O. Box 1021, Eatontown, NJ 07724; Phone: 800-790-3249; Fax: 732-676-2659 1. Employee Information Employee Name Today's Date Address Employer Name ____ Check if new address Social Security Number 2. OxfordFlex Healthcare Please complete this form in its entirety and attach an itemized statement, insurance explanation of benefits or receipt. Please review the instructions prior to completing this form. Patient Name Date of Service Relation to Employee Name of Provider Description of Service Amount Requested Total Amount Requested: 3. OxfordFlex Dependent Care Complete this form and attach an itemized statement from your day care provider or have your provider complete the information below. IRS Regulations allow payment for services that have already been provided, not for services to be provided in the future. IRS regulations require the provider to furnish their name, address and tax identification number (or SS#). If your day care provider completes and signs this form below, no other itemized statement is necessary. Dates of Service From To Dependent Name Age Provider Provider TIN/SSN Cost of Service/ Amount Requested Total Amount Requested: Day Care Provider's Original Signature X Provider Address 4. Claim Certification I certify that I have actually incurred these expenses. I certify that I have not been reimbursed for the above expense(s) and I will not seek reimbursement under any other plan covering health benefits. I understand that any amounts reimbursed may not be claimed on my or my spouse's personal income tax for the purpose of income or tax reduction. If I obtain reimbursement for these expenses which are later determined to be ineligible expenses as defined under the Internal Revenue Code for Section 125 qualified cafeteria plans, I agree to reimburse my OxfordFlex account as directed by my employer. The amount credited to my OxfordFlex plan for any Plan Year shall be used only to reimburse me for qualifying OxfordFlex Healthcare and OxfordFlex Dependent Care expenses incurred during such Plan Year while I was a Member, and only if I apply for reimbursement on or before the 90th day following the close of the Plan Year. Employee Signature Date X Note: OxfordFlex employer groups and members may want to consult a tax advisor regarding Section 125 qualified cafeteria plans and other reimbursement accounts permitted by the Internal Revenue Code. The employer, not Oxford Benefit Management (OBM), shall remain the group’s fiduciary for the group's health benefit plan. MS-03-1639 6696 R1 OxfordFlex Claim Submission Guidelines To ensure you are provided the best service and receive timely payment of your OxfordFlex claims, please follow the short list of guidelines and checklist we have created for you. The steps below highlight the information and documentation required for us to process your claim quickly without requesting additional information. OxfordFlex Healthcare Claims 1. If you have medical, dental or vision insurance, all expenses must be submitted to your insurance company before submitting for reimbursement. 2. When submitting a claim for reimbursement that is partially covered by your medical or dental insurance carrier (Oxford Health Plans or other carrier), you must: Complete the claim form and include the Explanation of Benefits (EOB), which indicates the out-of-pocket expense amount. 3. When submitting a claim for reimbursement for which no portion of the expense is covered by your medical or dental insurance carrier (Oxford Health Plans or other carrier), you must: Provide an itemized statement that includes: - the provider’s name and address - provider’s tax identification number (if applicable) - the date(s) of service - description of service (balance due statements are not sufficient) - the dollar amount charged 4. Balance forward statements, canceled checks, credit card receipts are not acceptable. 5. When requesting reimbursement for prescription drugs, medical equipment, vision services or specialized therapy you must include the following: Prescription medication - Please provide a receipt, which provides the patient’s name, the prescription number, the prescription name, and dollar amount. Medical equipment - A letter/note from the physician prescribing the equipment as treatment for a specific condition, (e.g., glucose monitor for diabetes). must be accompanied by a receipt identifying the brand name or type of item purchased. Specialized therapy - A letter/note from your physician prescribing the therapy as treatment for a specific medical condition. OxfordFlex Dependent Care Claims Claims for dependent care must be submitted with a receipt or statement from the daycare provider that substantiates the request for reimbursement. If you do not have enough contributions to cover the full expense, we will provide additional reimbursement once additional contributions are made to your account. Please provide an itemized statement that includes: - the name of the provider - the address of the provider - Social Security Number or Tax Identification number of the provider - the dates of service - the amount claimed Examples of documentation: 1. Commercially prepared/business-generated statement or receipt (commonly used by larger daycare facilities) 2. General receipt pad (provider signature recommended) 3. Handwritten or typed note (this can be generated by the provider or member) EXCEPTION: If care if provided by a relative, your canceled check may be used as documentation: however, if you pay the relative in cash, you must include a receipt. PAYMENT TO RELATIVE should be indicated on each claim form submitted. Vision services - An itemized receipt for glasses and/or contact lenses. Claims for enzyme cleaners and lens solutions Checklist for submitting your OxfordFlex Claim Did you remember to: ❑ Include your name ❑ Attach all required documentation for each expense ❑ Include your Social Security Number ❑ Indicate your requested reimbursement amount if different from your receipt totals ❑ List expenses for each family member (Dependent Care claims require the name and age of each dependent) ❑ Sign your claim form 6696
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