The easiest way to file a claim and track your spending is by logging in to your account via the secure web portal and uploading the appropriate documentation.
If you prefer to file a manual claim, please complete a Reimbursement Request Form. Do not forget to include the name of your employer and to sign and date the form.
By signing the form, the participant attests that the expense has not been and will not be reimbursed by any other source.
Attach required supplemental documentation, such as an Explanation of Benefits (EOB), and Itemized Statement or Pharmacy printout of prescriptions filled) to the Reimbursement Request. This documentation must include:
- The date of service
- The provider of services
- Procedure performed
- The amount you are being charged
Charge receipts, canceled checks, balance forwards, and paid on account receipts are not acceptable documentation.
Requests and documentation can be submitted via fax: 601-715-1855.
The frequency of claims processing is determined by your employer.