How do I submit a Medical Expense Form?

What do I need to submit a medical expense form?

You can complete your medical expense form online here

Completing a medical expense form requires detailed information. Please provide as much as you can to ensure timely processing. Missing information may delay processing.

If you are completing this for your medical provider, one of the most important things to include is the ICD-10 Diagnostic code, or you can just ask your provider for the CMS1500/HCFA form or UB04 form to submit on their behalf. If you have any questions, please reach out to Member Services at 855-378-6777.


Not sure where to find the information required?

If you have a form that looks like this red form, please just attach it to your request. It will have all the information we need.  


Screen Shot 2021-07-16 at 11.11.27 AM

Screen Shot 2021-07-16 at 11.11.49 AM


Screen Shot 2021-07-16 at 11.12.03 AM