Trivantage Welness Benefit Reimbursement Form - Mvp Heath Care
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1
2TRIVANTAGE WELLNESS BENEFIT
REIMBURSEMENT FORM
• Please use this form to request reimbursement of wellness services or activities based on your Plan’s specific
wellness benefit. Reimbursement forms must be received no later than one year after the service or activity
was paid for.
• PLEASE PRINT. For more information on completing this form, see reverse.
MVP Subscriber ID #
MEMBER INFORMATION
Last Name:
First Name:
Middle Initial:
Address:
City:
State:
Zip Code:
Phone Number:
Date of Birth (mm/dd/yyyy):
REIMBURSEMENT REQUEST
Name, address and phone number of
Description of Service
Amount Paid Date of Payment
Service Provider
Total number of receipts attached:
Total paid: $
MVP will provide reimbursement of the TriVantage Credit in the amount of $299.99 as standard practice. If you prefer the
reimbursement of $300, please check this box
CERTIFICATION AND AUTHORIZATION
I authorize the release of information about my Wellness Program utilization to my health plan. I certify that the information provided in
support of this submission is complete and accurate and that I have not previously submitted for or been reimbursed for these same
services.
Subscriber’s Signature
Date
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact
material thereto, commits a fraudulent insurance act, which is a crime and shall be subject to a civil penalty not to exceed five thousand
dollars and the stated value of the claim for each such violation.
RETURN TO: MVP Health Care®, Wellness Benefit Reimbursement, 625 State Street, P.O. Box 2207, Schenectady, NY 12301
FOR OFFICE USE ONLY
Provider #
HDOLLAR
Date of Payment
POS
CPT/HCPCS
ICD-9 Dx* ICD-10 Dx**
Charges
From
To
99
S9446 Youth Sports & TriVantage
V689
Z029
MM
DD
YY
MM
DD
YY
99
S9449 Healthy Weight Support
V689
Z029
99
S9970 Gym/Fitness & TriVantage Active
V689
Z029
99
S9986 TriVantage Healthy Alternative
V689
Z029
99
99199 Non-Covered
V689
Z029
*(DOS < 10/1/15) **(DOS 10/1/15 and later)
Total:
(10/15) EFF 1/16
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