Fillable Health Care Account How to File a Claim (Duke University)

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Health Care Account How to File a Claim (Duke University)

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Tips For Claim Submission
An eligible dependent is defined as a spouse, qualifying child, or
qualifying relative.
• Aqualifyingchildisdenedasataxdependentchilduptoage26
or any age if permanently disabled.
• Aqualifyingrelativeissomeonewhoresideswithyouformore
than half of the year.
• Qualifyingchildrenandrelativesmustnotprovidemorethanhalf
ofhis/herownsupport.
Forinformationtoclaimorthodontiaexpenses,referto:www.hr.duke.
edu//benets/medical/reimbursement/health/orthodontia.php.
Foracompletelistofeligibleexpensesspecictoyourplan,login
to your account at www.hr.duke.edu/reimbursement and select
“EligibleExpense”fromtheleftsideofthescreen.Onlysubmitclaims
foreligibleexpenses.
Aletterofmedicalnecessityisrequiredforanyexpenselistedas
“Yes(Letter)”ontheeligibleexpenselisttoestablishmedicalnecessity.
Cosmeticsurgeryorprocedures(i.e.teethwhitening)arenoteligible
expensesunlessdeemedasmedicallynecessarybyalicensed
physician.Aletterofmedicalnecessityformcanbeobtainedat:
www.hr.duke.edu/benets/medical/reimbursement/health/
Medical_Necessity.pdf.
Tip for Over-the-Counter Expenses
Aprescriptionisrequiredforanyover-the-counterexpenselistedas
“Yes(Rx)”ontheeligibleexpenselist.AsaresultoftheHealthCare
ReformLaw,inadditiontotherequireddetailedreceipt,anactual
prescriptionwrittenbyadoctor(onaprescriptionpadorform)
datedonorbeforethedatetheexpensewasincurredisrequiredto
verifythattheover-the-countermedicineisprescribedforaknown
medical condition.
Tips For Documentation
Ensure that the documentation is legible.
Cancelled or copies of checks and credit card receipts do not contain
all6requiredpiecesofinformationneededtoapproveyourexpense,
and are not acceptable for submission.
ExplanationofBenets(EOBs)arerecommended,especiallyifyour
insurancecoveredaportionoftheexpense.
The use of a highlighter causes items to not be legible on the
documentation; highlighter use is not recommended.
Send only photocopies of your claim form and documentation – keep
the originals for your records if submitting via US Mail.
Your provider may sign the form confirming the date of services,
charges and other service or product information in lieu of providing
separate documentation or other proof of service.
Tips For Faxing
Donotuseacoverpagewhenfaxingtheclaimformand
documentation.
Submitonlyclaimsforyourownaccount.
Tips for Viewing Claim Status
Pleaseallow2businessdaysfromreceiptofyourclaimforprocessing.
Youwillbenotiedviaemailofthestatusofyourclaimifwehavea
valid email address on file (to update your email address, please log
in to your account at www.hr.duke.edu/reimbursement and select
“Prole”intheupperrightcornerofthescreen).
Questions?
CallWageWorksCustomerServiceat1-877-924-3967.
Health Care Account
How to File a Claim for Approval
www.wageworks.com
Instructions to ll out this form:
Complete ALL account holder information.
Provideyouremployernamewithout
abbreviation.
Use your documentation to complete each
sectionoftheform,includingthefollowing:
Provider Name
Service Date(s)
Patient Name and Relationship to
AccountHolder
Type of Service
Patient Responsibility
Provider Signature is not required,
but can replace need for other proof
of service
Health Care Account
Pay Me Back Claim Form
www.wageworks.com
File claim online - Join the growing majority of participants who submit their claim
online for faster service. Log in to your account at www.hr.duke.edu/reimbursement
to le your claim electronically and upload your documentation.
File claim via fax or mail - Claim forms may also be filed either via fax or US Mail
and sent to the following locations:
Fax: 877-353-9236, US Mail: CLAIMS ADMINISTRATOR, P.O. Box 14053, Lexington, KY, 40512
Claim processing time - Claims will be processed within 2 business days after WageWorks receives the form.
You may check the status of your claim by logging into your account at www.hr.duke.edu/reimbursement.
ACCOUNT HOLDER:
Last Name First Name
Employer Name
ID Code* Zip Code
* ID Code is the last 4 digits of your Duke Unique ID number.
PROVIDER NAME
SERVICE DATES
(Start and End Dates)
(MM/DD/YY)
PATIENT NAME, RELATIONSHIP TO ACCOUNT HOLDER
AND TYPE OF SERVICE
OUT-OF-POCKET
COST
Patient Name: _______________________________________________________
Relationship to Account Holder:
Signature of Provider:
(Replaces the need for other proof of service.)
Patient Name: _______________________________________________________
Relationship to Account Holder:
Signature of Provider:
(Replaces the need for other proof of service.)
Patient Name: _______________________________________________________
Relationship to Account Holder:
Signature of Provider:
(Replaces the need for other proof of service.)
Patient Name: _______________________________________________________
Relationship to Account Holder:
Signature of Provider:
(Replaces the need for other proof of service.)
More expenses? Please complete another form. CLAIM FORM TOTAL:
CERTIFICATION AND AUTHORIZATION: I certify that the information on this form is accurate and complete. I am requesting reimbursement for eligible deductible expenses incurred by
myself or an eligible dependent while I was a participant in the plan. (Patient & Relationship is assumed to be Self unless otherwise indicated.) I have already received these products and services
and confirm that by requesting reimbursement here that I have not and will not seek reimbursement of this expense from any other plan or party. If I am covered under more than one health
care account, reimbursement will be made according to the payment order determined by those plans and as stated on the WageWorks website. Use of this service indicates my acceptance of
the WageWorks User Agreement at www.wageworks.com (available upon registration; enter username and password or click on First Time User? link).
WW-7605-HC-PMB-DUKE (Dec 2012)
Self
Spouse
Qualifying Child
Qualifying Relative
Other: __________________
Type of Service:
Rx
Dental
Psych/Therapy
Ortho
Chiro
Co-payment
Lab
Vision
Hospital
X-Ray
OTC
Office Visit
Other: _______________________
Type of Service:
Rx
Dental
Psych/Therapy
Ortho
Chiro
Co-payment
Lab
Vision
Hospital
X-Ray
OTC
Office Visit
Other: _______________________
Type of Service:
Rx
Dental
Psych/Therapy
Ortho
Chiro
Co-payment
Lab
Vision
Hospital
X-Ray
OTC
Office Visit
Other: _______________________
Type of Service:
Rx
Dental
Psych/Therapy
Ortho
Chiro
Co-payment
Lab
Vision
Hospital
X-Ray
OTC
Office Visit
Other: _______________________
$
.
,
$
$
$
$
Self
Spouse
Qualifying Child
Qualifying Relative
Other: __________________
Self
Spouse
Qualifying Child
Qualifying Relative
Other: __________________
Self
Spouse
Qualifying Child
Qualifying Relative
Other: __________________
.
,
.
,
.
,
.
,
DUKE
SM I TH JOH N
5421 10063
Mercy Hospital
Dr. Mark Johnson, M.D.
Mercy Pharmacy
010512
010512
01 1412
01 1412
John Smith
Mary Smith
25 00
1 0 70
WW-7605-HC-PMB-DUKE(Dec2012)
Claim Filing Options:
File claim online - Log in to your account at www.hr.duke.edu/reimbursement to submit your claim electronically.
File claim via fax or mail -Claimdetailsmaybeenteredonlineandacompletedformmaybeprintedandfaxedormailedwith
documentation. Fax:877-353-9236,US Mail:CLAIMSADMINISTRATOR,P.O.Box14053,Lexington,KY,40512
Health Care Account
Pay Me Back Claim Form
File claim online-Jointhegrowingmajorityofparticipantswhosubmittheirclaim
online for faster service. Log in to your account at www.hr.duke.edu/reimbursement
to le your claim electronically and upload your documentation.
File claim via fax or mail -ClaimformsmayalsobeledeitherviafaxorUSMail
andsenttothefollowinglocations:
Fax:877-353-9236,US Mail:CLAIMSADMINISTRATOR,P.O.Box14053,Lexington,KY,40512
Claim processing time-Claimswillbeprocessedwithin2businessdaysafterWageWorksreceivestheform.
You may check the status of your claim by logging into your account at www.hr.duke.edu/reimbursement.
ACCOUNT HOLDER:
Last Name First Name
Employer Name
ID Code* Zip Code
*IDCodeisthelast4digitsofyourDukeUniqueIDnumber.
PROVIDER NAME
SERVICE DATES
(Start and End Dates)
(MM/DD/YY)
PATIENT NAME, RELATIONSHIP TO ACCOUNT HOLDER
AND TYPE OF SERVICE
OUT-OF-POCKET
COST
Patient Name: _______________________________________________________
Relationship to Account Holder:
Signature of Provider:
(Replaces the need for other proof of service.)
Patient Name: _______________________________________________________
Relationship to Account Holder:
Signature of Provider:
(Replaces the need for other proof of service.)
Patient Name: _______________________________________________________
Relationship to Account Holder:
Signature of Provider:
(Replaces the need for other proof of service.)
Patient Name: _______________________________________________________
Relationship to Account Holder:
Signature of Provider:
(Replaces the need for other proof of service.)
More expenses? Please complete another form. CLAIM FORM TOTAL:
CERTIFICATION AND AUTHORIZATION:Icertifythattheinformationonthisformisaccurateandcomplete.Iamrequestingreimbursementforeligibledeductibleexpensesincurredby
myselforaneligibledependentwhileIwasaparticipantintheplan.(Patient&RelationshipisassumedtobeSelfunlessotherwiseindicated.)Ihavealreadyreceivedtheseproductsandservices
andconrmthatbyrequestingreimbursementherethatIhavenotandwillnotseekreimbursementofthisexpensefromanyotherplanorparty.IfIamcoveredundermorethanonehealth
careaccount,reimbursementwillbemadeaccordingtothepaymentorderdeterminedbythoseplansandasstatedontheWageWorkswebsite.Useofthisserviceindicatesmyacceptanceof
the WageWorks User Agreement at www.wageworks.com(availableuponregistration;enterusernameandpasswordorclickonFirstTimeUser?link).
WW-7605-HC-PMB-DUKE(Dec2012)
Self
Spouse
QualifyingChild
QualifyingRelative
Other: __________________
Type of Service:
Rx
Dental
Psych/Therapy
Ortho
Chiro
Co-payment
Lab
Vision
Hospital
X-Ray
OTC
OceVisit
Other: _______________________
Type of Service:
Rx
Dental
Psych/Therapy
Ortho
Chiro
Co-payment
Lab
Vision
Hospital
X-Ray
OTC
OceVisit
Other: _______________________
Type of Service:
Rx
Dental
Psych/Therapy
Ortho
Chiro
Co-payment
Lab
Vision
Hospital
X-Ray
OTC
OceVisit
Other: _______________________
Type of Service:
Rx
Dental
Psych/Therapy
Ortho
Chiro
Co-payment
Lab
Vision
Hospital
X-Ray
OTC
OceVisit
Other: _______________________
$
.
,
$
$
$
$
Self
Spouse
QualifyingChild
QualifyingRelative
Other: __________________
Self
Spouse
QualifyingChild
QualifyingRelative
Other: __________________
Self
Spouse
QualifyingChild
QualifyingRelative
Other: __________________
.
,
.
,
.
,
.
,
DUKE
www.wageworks.com
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Health Care Account How to File a Claim (Duke University)

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Completed 30 November 2021

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