Wageworks Claim Form
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1
2Health Care Account
How to File a Claim for Approval
Health Care Account
Claim Filing Options:
Pay Me Back Claim Form
File claim online - Log in to your account at to submit your claim electronically.
File claim online - Join the growing majority of participants who submit their claim
online for faster service. Log in to your account at to file your
File claim via fax or mail - Claim details may be entered online and a completed form may be printed and faxed or mailed with
claim electronically and upload your documentation.
File claim via fax or mail - Claim forms may also be filed either via fax or US Mail
documentation. Fax: 877-353-9236 , US Mail: CLAIMS ADMINISTRATOR, P.O. Box 14053, Lexington, KY, 40512
and sent to the following locations:
Fax: 877-353-9236, US Mail: CLAIMS ADMINISTRATOR, P.O. Box 14053, Lexington, KY, 40512
Claim processing time - Claims will be processed within 2 business days after WageWorks receives the
form. You may check the status of your claim by logging into your account at .
Instructions to fill out this form:
ACCOUNT HOLDER:
S M I T H
J O H N
Complete ALL account holder information.
Last Name
First Name
Provide your employer name without
J O N E S
G R A P H I C S
abbreviation.
Employer Name
Use your documentation to complete each
* ID Code is the last 4 digits of your Social Security Number, your Employee ID number or other reference number
5 4 2 1
1 0 0 6 3
assigned by your employer. Please check the enrollment instructions provided by your program sponsor for more
information about your ID Code.
section of the form, including the following:
ID Code*
Zip Code
Provider Name
SERVICE DATES
PATIENT NAME, RELATIONSHIP TO ACCOUNT HOLDER
OUT-OF-POCKET
PROVIDER NAME
(Start and End Dates)
AND TYPE OF SERVICE
COST
(MM/DD/YY)
‚
Service Date(s)
0 1 0 5 1 2
John Smith
Mercy Hospital
Patient Name: _______________________________________________________
0 1 0 5 1 2
ƒ
Relationship to Account Holder:
Type of Service:
Patient Name and Relationship to
Self
Lab
Rx
Signature of Provider:
Spouse
Vision
Dental
$
2 5 0 0
Account Holder
Qualifying Child
Psych/Therapy
Hospital
(Replaces the need for other proof of service.)
,
.
Qualifying Relative
X-Ray
Ortho
Dr. Mark Johnson, M.D.
Other: __________________
Chiro
OTC
„
Type of Service
Office Visit
Co-payment
Other: _______________________
0 1 1 4 1 2
…
Mary Smith
Patient Responsibility
Patient Name: _______________________________________________________
Mercy Pharmacy
0 1 1 4 1 2
Relationship to Account Holder:
Type of Service:
Self
†
Rx
Lab
Provider Signature is not required,
Signature of Provider:
Spouse
Vision
Dental
$
1 0 7 0
Qualifying Child
Psych/Therapy
Hospital
(Replaces the need for other proof of service.)
,
.
but can replace need for other proof
Qualifying Relative
X-Ray
Ortho
Other: __________________
Chiro
OTC
Co-payment
Office Visit
of service
Other: _______________________
Patient Name: _______________________________________________________
Relationship to Account Holder:
Type of Service:
Self
Lab
Rx
Signature of Provider:
Spouse
Dental
Vision
$
Qualifying Child
Hospital
(Replaces the need for other proof of service.)
Psych/Therapy
,
.
Qualifying Relative
Tips For Claim Submission
Tips For Documentation
Ortho
X-Ray
Other: __________________
Chiro
OTC
Office Visit
Co-payment
Other: _______________________
Ensure that the documentation is legible.
An eligible dependent is defined as a spouse, qualifying child, or
Patient Name: _______________________________________________________
qualifying relative.
Relationship to Account Holder:
Type of Service:
Cancelled or copies of checks and credit card receipts do not contain
Self
Rx
Lab
Signature of Provider:
Spouse
Vision
Dental
• A qualifying child is defined as a tax dependent child up to age 26
$
all 6 required pieces of information needed to approve your expense,
Qualifying Child
Psych/Therapy
Hospital
(Replaces the need for other proof of service.)
,
.
Qualifying Relative
X-Ray
Ortho
or any age if permanently disabled.
Other: __________________
and are not acceptable for submission.
Chiro
OTC
Office Visit
Co-payment
• A qualifying relative is someone who resides with you for more
Other: _______________________
Explanation of Benefits (EOBs) are recommended, especially if your
$
More expenses? Please complete another form.
CLAIM FORM TOTAL:
than half of the year.
,
.
insurance covered a portion of the expense.
CERTIFICATION AND AUTHORIZATION:
• Qualifying children and relatives must not provide more than half
I certify that the information on this form is accurate and complete. I am requesting reimbursement for eligible deductible expenses incurred by
myself or an eligible dependent while I was a participant in the plan. (Patient & Relationship is assumed to be Self unless otherwise indicated.) I have already received these products and services
The use of a highlighter causes items to not be legible on the
and confirm that by requesting reimbursement here that I have not and will not seek reimbursement of this expense from any other plan or party. If I am covered under more than one health
of his/her own support.
care account, reimbursement will be made according to the payment order determined by those plans and as stated on the WageWorks website. Use of this service indicates my acceptance of
the WageWorks User Agreement at (available upon registration; enter username and password or click on First Time User? link).
documentation; highlighter use is not recommended.
WW-HC-PMB (Oct 2012)
For information to claim orthodontia expenses, refer to the guide
Send only photocopies of your claim form and documentation – keep
located at: https:// /employee/learning-center/
the originals for your records if submitting via US Mail.
ClaimOrthodontiaExpense.html.
Your provider may sign the form confirming the date of services,
For a complete list of eligible expenses specific to your plan, log in to
charges and other service or product information in lieu of providing
your account at and select “Eligible Expense”
separate documentation or other proof of service.
from the left side of the screen. Only submit claims for eligible
expenses.
Tips For Faxing
A letter of medical necessity is required for any expense listed as
“Yes (Letter)” on the eligible expense list to establish medical necessity.
Do not use a cover page when faxing the claim form and
Cosmetic surgery or procedures (i.e. teeth whitening) are not eligible
documentation.
expenses unless deemed as medically necessary by a licensed
Submit only claims for your own account.
physician. A letter of medical necessity form can be obtained at:
https:// /forms/WW-LTR-OF-MED-NEC.pdf .
Tips for Viewing Claim Status
Please allow 2 business days from receipt of your claim for processing.
Tip for Over-the-Counter Expenses
You will be notified via email of the status of your claim if we have a
A prescription is required for any over-the-counter expense listed as
valid email address on file (to update your email address, please log
“Yes (Rx)” on the eligible expense list. As a result of the Health Care
in to your account at and select “Profile” in the
Reform Law, in addition to the required detailed receipt, an actual
upper right corner of the screen).
prescription written by a doctor (on a prescription pad or form)
dated on or before the date the expense was incurred is required to
verify that the over-the-counter medicine is prescribed for a known
medical condition.
WW-HC-PMB (Nov 2012)
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