Fillable MEDICARE REIMBURSEMENT ACCOUNT (MRA) CLAIM FORM INSTRUCTIONS HOW

Fill Online, Printable, Fillable, Blank MEDICARE REIMBURSEMENT ACCOUNT (MRA) CLAIM FORM INSTRUCTIONS HOW Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

MEDICARE REIMBURSEMENT ACCOUNT (MRA) CLAIM FORM INSTRUCTIONS HOW

On average this form takes 4 minutes to complete

The MEDICARE REIMBURSEMENT ACCOUNT (MRA) CLAIM FORM INSTRUCTIONS HOW form is 2 pages long and contains:

  • 0 signatures
  • 2 check-boxes
  • 14 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
MEDICARE REIMBURSEMENT ACCOUNT (MRA)
CLAIM FORM INSTRUCTIONS
HOW TO SUBMIT CLAIMS BY FAX OR MAIL
IMPORTANT
Don’t include this instruction page with your faxed or mailed claim form.
FILLING OUT YOUR CLAIM FORM
1. Account Holder Information
Please print or write legibly when completing the account holder rst and last name. Complete a separate form for your
spouse and/or covered dependents.
2. Claims for Out-of-Pocket Expenses
This section should be lled out according to how your Medicare Part B premiums are paid.
Check the rst box if your Medicare Part B premium is deducted from your Social Security or Annuity check.
Check the second box if your Medicare Part B premium is not deducted from your Social Security or Annuity check and is paid
by you on an after-tax basis.
Your service start date is either January 1 of the year for which you are requesting reimbursement, your eective date if after
the rst of the year, or the rst of the month(s) if you pay out-of-pocket on a monthly/quarterly basis.
Your service end date is either December 31 of the year for which you are requesting reimbursement or the last day of the
month(s) if you pay out-of-pocket on a monthly/quarterly basis.
Fill in the total annual or monthly/quarterly amount of your Medicare Part B payment.
3. Proof of Payment
Attach proof of Medicare Part B premium payment.
SELECTING YOUR PROOF OF PAYMENT DOCUMENTS
The Internal Revenue Service (IRS) requires you to provide documents to verify that you paid for a
Medicare Part B premium. At a minimum, the document(s) must show:
The date you paid your Medicare premium
The Medicare Part B account holder’s name
The name of your insurance carrier (Blue Cross and Blue Shield Service Benet Plan)
The type of expense (Medicare Part B premium)
Proof of premium payment (such as a cleared check, bank statement, or credit card
statement that shows the amount you paid for the Medicare Part B premium)
The Blue Cross® and Blue Shield® words and symbols, Federal Employee Program® and FEP® are all trademarks owned by Blue Cross Blue Shield Association.
MEDICARE REIMBURSEMENT ACCOUNT (MRA)
PAY ME BACK CLAIM FORM
• Print or write legibly.
• Do not use a fax cover sheet.
Submit your completed claim via toll-free fax: (877) 353-9236
OR mail: Claims Administrator, PO Box 14053 Lexington, KY 40512
MEMBER INFORMATION
1
Last Name First Name
*WFHC*
B C B S S E R V I E B E N E F I T P L A N
Employer Name
Your ID code is a 4-digit combination of your day of birth and
the last 2 digits of your SSN. For example, if you were born on
the 8th day of the month and the last 2 digits of your SSN are
12, your ID Code would be 0812.
ID Code* Date of Birth (MM/DD) Zip Code
2
CLAIMS FOR OUT-OF-POCKET EXPENSES
Check one:
My Medicare premiums are automatically deducted from my Social Security or Annuity check. (Enter annual amount)
I pay my Medicare premiums after-tax. They are not automatically deducted from my Social Security or Annuity check.
(Enter monthly/quarterly amount)
$
Service Start Date Service End Date Out-of-Pocket Cost
(MM/DD/YY) (MM/DD/YY)
3
SUBMIT YOUR PROOF OF PAYMENT
Include proof of payment as an attachment to this form that shows you pay Medicare Part B premiums. Remember to keep
the originals of the documents you submit.
If you checked the first box in step 2 above, please submit a copy of your Cost of Living Adjustment (COLA) statement or
Annuity Statement.
If you checked the second box in step 2 above, please submit a copy of your Medicare Bill along with your proof of payment
(such as a cleared check or bank or credit card statement).
Date
I certify that the information on this form is accurate and complete. I am requesting reimbursement for Medicare Part B premium expenses I incurred
while a member of the Blue Cross and Blue Shield Service Benet Plan. I have not/will not seek reimbursement of this expense from any other plan or
party because I:
1) pay for the premiums through withholding, 2) have paid for the premiums out-of-pocket.
Use of this service indicates my acceptance of the User Agreement at fepblue.org/mra (available upon registration; enter username and password or click on
First Time User).
4416-BCBS-MRA-PMB-FRM (202007)
C
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MEDICARE REIMBURSEMENT ACCOUNT (MRA) CLAIM FORM INSTRUCTIONS HOW

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 6 July 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document