Community Health Education - Reimbursement Form (Page 2 of 2) in pdf

Community Health Education - Reimbursement Form Page 2

Submission Instructions

The Community Health Education Reimbursement Form needs to be completed by the member

attending the program. Submit only one form per member per program.

Example:

John Doe attended Freedom From Smoking 1/1 - 1/28 = one form

John Doe attended How to Begin Exercising 1/15 = one form

Jane Doe attended Freedom From Smoking 1/1 - 1/28 = one form

The Participating Vendor will:

1. Assist the member in filling out the unshaded sections.

2. Collect the member’s class fee up-front and record amount paid in section 14.

3. Verify all the information is correct and sign sections 16 and 19.

4. Have the member sign section 20 and date section 21.

5. Submit the completed claim form to the address listed below.

For Yoga and Weight Watchers Classes Only, the Member will:

1. Have the instructor record the amount paid in section 14.

2. Have the instructor sign sections 16 and 19 to verify class attendance.

3. Verify all the information is correct, sign section 20 and date section 21.

4. Retain a copy if desired (form will not be returned).

5. Submit the completed claim form within 30 days after program completion to the address

listed below.

Claims Submission Address:

Claims Department

Anthem Blue Cross and Blue Shield

PO Box 533North Haven, CT 06473-0533

Member reimbursement will be denied if:

1. The member was not a current or eligible Anthem Blue Cross and Blue Shield member

when class was attended, or

2. The member did not complete the program (allowed to miss maximum of one class per

series).

This form will be returned if:

. The form is not completed with the required information.

SPECIAL NOTE: Because Anthem Blue Cross and Blue Shield products vary,

members should check with Customer Service to verify their eligibility for this

program. The Customer Service phone number is located on the back of the member’s

ID card.

Community Health Education - Reimbursement Form Page 2