Transcription of Pick Your Perks Claim Form - Network Health | Home
{{id}} {{{paragraph}}}
Example: barber
Pick Your Perks Claim Form - Network Health | Home
To request reimbursement electronically, visit your Network Health portal at To request reimbursement manually, read these instructions thoroughly, complete the form on the next page, and return both pages by Member Information. Complete the section in Expense Information. Submit a max of two expenses per form . For more than two expenses, submit additional forms. When purchasing multiple over-the-counter items, submit an entire receipt/purchase as one expense. A. Benefit Type. Enter the benefit type listed for your eligible expense. For more details about your eligible expenses, refer to your plan materials in your Network Health member TypeRequired DocumentationNotesDentalItemized receiptCosmetic dentistry, orthodontia and services covered by Medicare are excludedVision hardwareItemized receiptCosmetic items, warranties and Lasik are excludedNon-emergency transportation with AryvNoneMust use plan-approved vendor, AryvHome-delivered meals with Mom s MealsItemized receipt-and-Proof of inpatient, outpatient or S
Network Health Medicare Advantage Plans include MSA, HMO and PPO plans with a Medicare contract. Enrollment in Network Health Medicare Advantage Plans Employee Benefits Corporation 1 depends on contract renewal. H52152958-2-12M Accepted 12722 Pick Your Perks 2021 Reimbursement Claim Form Instructions
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: