For each reimbursement request, you will need the following:
- The name of your provider;
- Their mailing address and phone number;
- Their provider Tax ID;
- Their provider NPI;
- Diagnosis Codes (check the Eligible Diagnoses page on this website for more information);
- Code for Services Rendered (check the Outpatient Services page on this website for more information);
For physical injuries related to mental health and their treatments, in addition to all the above, please include:
- Written approval from your mental health provider, which confirms that the physical injury and its accompanying treatment are related to treatment for mental health.
The diagnosis (DX) and service codes should be included on each bill, invoice and/or Explanation of Benefits. Your bills should be itemized by date and service.
If you're covered by a health insurance plan, you will also need the policy holder name, group number, insurance company, and state.
All reimbursement requests need to have supporting documentation attached. Failure to submit appropriate documents will delay consideration for reimbursement.