Claim reimbursement form

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Claim reimbursement, made easy.

Please review below our description of the claims reimbursement process and note the information you’ll need available. Unfortunately, we can only process one prescription per claims reimbursement submission at this time.  

As easy as 1, 2, 3...

Our claims reimbursement process is quick, simple and just requires you to enter some basic information about your claim and prescription.

1

Enter patient information

2

Upload and enter claims information

3

Provide mailing address and signature

Materials needed

Be sure to have the following materials and information on hand as you’ll need it to fill out the claim reimbursement form.

Pharmacy receipt(s)

To submit your claims reimbursement request, you’ll need to upload your pharmacy receipt as proof of purchase for your prescription. Your pharmacy receipt (not to be confused with your store or register receipt) is typically attached to or included with your medication, or it can be obtained by contacting your pharmacy or via their website or app. Please attach documentation or images of your receipt in an upright, vertical orientation. A clear and unobstructed image is critical; please avoid any shadows, reflections, or obstructions that could impede readability. If you do not have the means to upload a pharmacy receipt, please consider submitting by mail.

Prescription details

Before submitting your request for claim reimbursement, you’ll need to have your prescription details available, which include the dose, Rx number, NDC (national drug code), and prescription fill date, all of which should be located on your pharmacy receipt.

Prescriber and pharmacy information

You’ll also need to confirm the prescriber for your prescription(s), and enter in their name and location, as well as the name and location of the pharmacy corresponding to your prescription. 

Mailing address and patient information

If your claims reimbursement request is accepted, we’ll send you a check by mail to your provided mailing address. Please be ready to provide your preferred mailing address and contact information.

Claim reimbursement form

Claim reimbursement, made easy.

Please review below our description of the claims reimbursement process and note the information you’ll need available. Unfortunately, we can only process one prescription per claims reimbursement submission at this time.

1

Patient information

Filing for yourself, household members, or care recipients

If filing on behalf of yourself or a care recipient or household member on your Optum Rx account, sign in using the link at the bottom of this page. Once signed in, you’ll be given an option to select whom you’re filing this claim for.

OR

Filing on behalf of a patient

If you are filing for reimbursement on behalf of a patient, please have at least one of the following documents ready to upload to verify your representation, or use the forms provided below:

  • CMS-1696 form
  • Power of Attorney (POA) form
  • Guardianship papers
  • Court order
  • Executor of estate documentation forms
  • Health care proxy document(s)

2

Upload and enter claim information

Pharmacy receipt

First, you’ll need to upload your pharmacy receipt as proof of purchase for your prescription. Your pharmacy receipt (not to be confused with your store receipt) is typically attached to your medication, or it can be obtained by contacting your pharmacy or via their website or app. Please attach images of your receipt in an upright, vertical orientation. A clear and unobstructed image is critical; please avoid any shadows, reflections, or obstructions that could impede readability. If you do not have the means to upload a pharmacy receipt, please consider submitting by mail.

Prescription details

Before submitting your request for claim reimbursement, you’ll need to have your prescription details available, which include the dose, Rx number, NDC (national drug code), and prescription fill date, all of which should be located on your pharmacy receipt.

Prescriber and pharmacy information

You’ll also need to confirm the prescriber for your prescription(s), and enter in their name and location, as well as the name and location of the pharmacy corresponding to your prescription. 

3

Provide mailing address and signature

Filing for yourself, household members, or care recipients

If your claims reimbursement request is accepted, we’ll send you a check by mail to your provided mailing address. Please be ready to provide your preferred mailing address and contact information.

Filing on behalf of a patient

If you’re filing on behalf of a patient, please enter your patient’s mailing address. If the claims reimbursement request is accepted, we’ll send them a check by mail.

Who are you filing this claim for?

Myself, a household member, a dependent, or a care recipient

Please sign in using your HealthSafe ID to continue.

On behalf of a patient

Please have your proof of representation or guardianship on hand before you submit your claim. 

Patient information

Tell us about your claim

Please let us know the patient you are filing this claim for and for what reasons you are requesting reimbursement.

Please let us know for what reasons you are requesting reimbursement.

Who are you requesting claim reimbursement for?

Which care recipient or household member?

Why are you requesting reimbursement?

Tell us about your patient’s claim

Please let us know the patient you are filing this claim for and for what reasons you are requesting reimbursement.

You have [no_of_errors] field(s) that need to be corrected:

Patient information

Fields marked with an asterisk * are required.

Your information

Fields marked with an asterisk * are required.

Your proof of patient representation

(e.g. At least one of the following documents: CMS-1696, POA, guardianship papers, court orders, or health care proxy)

file
Drag and drop your file here or
Accepted file formats include .pdf, .jpg, and .png (up to 50 MB in size)

    Your address

    Fields marked with an asterisk * are required. Please do not enter the patient’s address here.

    Why are you requesting reimbursement for this patient?

    Why are you requesting reimbursement?

    Compounded prescriptions

    When submitting a claim for compounded medications, please note that only one drug or product ingredient can be entered. For compounded medications, use your pharmacy receipt to identify the most frequently used or most expensive ingredient in the mixture and enter its details. Your pharmacy receipt should list the ingredient’s amounts (in mg, ml, etc.) and/or the price for each ingredient. Your pharmacy receipt (not to be confused with your store or register receipt) is typically attached to or included with your medication, or it can be obtained by contacting your pharmacy or via their website or app. If your pharmacy receipt does not include the price or amount of each ingredient, please contact your pharmacy to obtain this information. When prompted for the total cost, please use the cost of your entire compounded medication, not just your selected ingredient.

    Loading claim reimbursement form...

    Claim information

    Pharmacy receipt

    Please upload your pharmacy receipt as proof of purchase for your claim reimbursement. You must upload a file before continuing with the form.

    file
    Drag and drop your file here or
    Accepted file formats include .pdf, .jpg, and .png (up to 5 MB in size)

      Prescription information

      Please enter your claim amount and prescription information as well as the corresponding prescriber and pharmacy information.

      Please save your claim information before continuing or your information will be lost

      Claim and prescription information

      Fields marked with an asterisk * are required.

      You have [no_of_errors] field(s) that need to be corrected:

      Please enter the date on which this prescription was filled. Fill date must be within the last 3 years.

      For over-the-counter medications, enter 123456789
      11-digit number

      You can find the NDC of your prescription near the drug name on your bottle or package, or on your pharmacy receipt. Leave the field blank if it's an over-the-counter medication, a foreign claim, or the NDC is unknown.

      How to find your NDC

      The National Drug Code or NDC is a unique 11-digit, 3 segment identifier for your medication. You can find the NDC of your prescription near the drug name on your prescription bottle or package.

      Please select the situation which best applies to this claim below. (This will be your DAW code number)

      Claim and prescription information

      Amount: $[amount]

      Date: [date]

      Rx #: [rx_number]

      Verify claim information

      [daw_desc]

      Medication information

      Medication information

      [medication_name]

      Quantity: [quantity]

      [day_supply]-day supply

      Verify medication information

      Search for your medication

      Fields marked with an asterisk * are required.

      Finding your
medication...

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      We’re currently working to fix it – and there’s a good chance it’s already been fixed. Please try again.

       

      If you do continue to experience issues, please contact us.

      Add medication

      You have [no_of_errors] field(s) that need to be corrected:

      [medication_name]

      Fields marked with an asterisk * are required.

      Total amount of medication per package

      (e.g. 60 capsules, 2 injections, etc.)

      Number of doses you receive per refill

      (e.g. 30-day, 90-day)

      No results found

      for “[medication_name]”

      We couldn’t find that medication

      Please check the spelling of your medication name and try a new search. You can also add medication information manually if you’re unable to find it in our system. 

      Medication information

      Add medication

      You have [no_of_errors] field(s) that need to be corrected:

      Fields marked with an asterisk * are required.

      (e.g., tablet, capsule, aerosal, etc.)

      (e.g. 10 mg, 80 mL, 30 mcg, etc.)

      Total amount of medication per package

      (e.g. 60 capsules, 2 injections, etc.)

      Number of doses you receive per refill

      (e.g. 30-day, 90-day)

      Prescriber information

      Prescriber information

      [prescriber_name]

      [street_address]

      [city_state]

      Verify prescriber information

      Search for your prescriber

      Fields marked with an asterisk * are required.

      FirstName LastName
      Enter your prescriber’s city and state or ZIP code

      Finding your
prescriber...

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      We’re currently working to fix it – and there’s a good chance it’s already been fixed. Please try again.

       

      If you do continue to experience issues, please contact us.

      Search results

      [no_of_prescribers] prescriber found:

      [no_of_prescribers] prescribers found:

      Page [current_page] of [total_pages]

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      We’re currently working to fix it – and there’s a good chance it’s already been fixed. Please try again.

       

      If you do continue to experience issues, please contact us.

      Add prescriber

      [prescriber_name]

      [speciality]

      Prescriber for:

      [medication_name]

      Where do you see them?

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      We’re currently working to fix it – and there’s a good chance it’s already been fixed. Please try again.

       

      If you do continue to experience issues, please contact us.

      No results found

      for “[prescriber_name]” near [location]

      We couldn’t find a prescriber with that information

      Please check the spelling of your prescribers’s name and try a new search. You can also add your prescriber manually if you can’t find them listed.

      Prescriber information

      Add prescriber

      You have [no_of_errors] field(s) that need to be corrected:

      Fields marked with an asterisk * are required.

       

      If this is an over-the-counter medication or you don't know the prescriber, enter N/A or select first drop-down value given in the field.

      Who are you seeing?

      Where are they located?

      Pharmacy information

      Pharmacy information

      [pharmacy_name]

      [street_address]

      [city_state]

      Verify pharmacy information

      Search for your pharmacy

      Fields marked with an asterisk * are required.

      Enter the name of your pharmacy
      Enter your pharmacy’s city and state or ZIP code

      Ouch! We ran into an issue.

      We’re currently working to fix it – and there’s a good chance it’s already been fixed. Please try again.

       

      If you do continue to experience issues, please contact us.

      Finding your

      pharmacy...

      Add pharmacy

      [no_of_pharmacies] pharmacy found:

      [no_of_pharmacies] pharmacies found:

      Page [current_page] of [total_pages]

      Ouch! We ran into an issue.

      We’re currently working to fix it – and there’s a good chance it’s already been fixed. Please try again.

       

      If you do continue to experience issues, please contact us.

      No results found

      for “[pharmacy_name]”

      We couldn’t find that pharmacy

      Please check the spelling of your pharmacy’s name and location and try a new search.

      Pharmacy information

      Add pharmacy

      You have [no_of_errors] field(s) that need to be corrected:

      Fields marked with an asterisk * are required.

      Which pharmacy filled your prescription?

      Enter the name of your pharmacy. If pharmacy details are unavailable, enter N/A and check the home delivery pharmacy box below.

      Where is your pharmacy located?

      If you use a home delivery pharmacy for this prescription rather than a retail pharmacy, please check the box below.

      Mailing address and signature

      Submitting your request

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      We’re currently working to fix it – and there’s a good chance it’s already been fixed. Please try again.

       

      If you do continue to experience issues, please contact us.

      Enter a mailing address

      Please choose the mailing address you’d like your claim reimbursement sent to, should it be accepted. If filing on behalf of a patient as a legal representative or custodial guardian, please enter the patient’s address.

      Select a mailing address

      Please choose the mailing address you’d like your claim reimbursement sent to, should it be accepted.

      Your addresses

      Add a new address

      Fields marked with a red asterisk * are required.

      You have [no_of_errors] field(s) that need to be corrected:

      Contact information

      Please confirm or enter your email address and phone number below

      Your email address

      [email_address]

      Your phone number

      [phone_number]

      Edit email address

      Fields marked with an asterisk * are required.

      Edit phone number

      Fields marked with an asterisk * are required.

      Patient representative contact information

      Please confirm or enter your email address and phone number below

      Email and phone number

      Fields marked with a red asterisk * are required.

      You have [no_of_errors] field(s) that need to be corrected:

      Review and sign

      I acknowledge my request for reimbursement will be paid directly to me and any assignment of benefits to a pharmacy or any other party related to this claim is void. Parties agree entering my name electronically below shall have the same force and effect as an original signature.

      Terms and conditions

      Any person who knowingly and with intent to defraud, injure, or deceive any insurance company, submit a claims or application containing any materially false, deceptive, incomplete or misleading information pertaining to such claim may be committing a fraudulent insurance act which is a crime and may subject such person to criminal or civil penalties, including fines and/or imprisonment, or denial of benefits. I certify that the medication(s) for which reimbursement is requested were received for use by the member above, and that I (or the member, if not myself) am eligible for prescription drug benefits. I also certify that the medications received were not for treatment of an on-the-job injury.

      Your claim has been successfully submitted

      Confirmation number: [confirmation_number]

      Checking your claim status

      Once your claim has been uploaded, you can check the current status of your reimbursement on your Claims page. Please allow up to 4-6 weeks for your claim to be fully processed. You can also print or download this page using the link in the top right. The reimbursement check will be mailed to the policy holder. Reimbursement will be issued to the policy holder, not the dependents, even if an adult dependent requests the reimbursement. This applies unless there is a legal custody agreement or other specific financial arrangements in place that dictate otherwise.

       

      If your claim is rejected, we will promptly send a detailed letter explaining the reasoning behind the rejection. You can also contact us and ask about your claim using your confirmation number.  If you need further assistance, please feel free to contact us.

      To check your claim status, please give us a call. Remember to have your confirmation number ready. Please allow up to 4-6 weeks for your claim to be fully processed. You can also print or download this page using the link in the top right. The reimbursement check will be mailed to the policy holder. Reimbursement will be issued to the policy holder, not the dependents, even if an adult dependent requests the reimbursement. This applies unless there is a legal custody agreement or other specific financial arrangements in place that dictate otherwise.

       

      If your claim is rejected, we will promptly send a detailed letter explaining the reasoning behind the rejection. You can also contact us and ask about your claim using your confirmation number.  If you need further assistance, please feel free to contact us.

      Patient and mailing information

      Patient representative

      [legal_rep_name]

      [legal_rep_email]

      [legal_rep_phone]

      [legal_rep_address]

      Form submitter

      [form_submitter_name]

      [form_submitter_email]

      [form_submitter_phone]

      Patient name

      [patient_name]

      Mailing address for reimbursement

      [address]

      Claim information

      Receipt or proof of purchase

      [receipt_name]

      Prescription information

      Amount: $[amount]

      Date: [date]

      Rx #: [rx_number]

      [daw_desc]  (DAW [daw_code])

      Medication information

      [prescription_name]

      Quantity: [no_of_dose]

      Prescriber and pharmacy

      [prescriber_name]

      [pharmacy_name]