Trivantage Welness Benefit Reimbursement Form - Mvp Heath Care (Page 2 of 2) in pdf

HOW TO SUBMIT YOUR REIMBURSEMENT REQUEST

1. This form may be used for Wellness reimbursement requests, only. The maximum credit is provided to each subscriber

(household). For example, a family of four would be eligible for one reimbursement per Plan per calendar year.

2. Reimbursement applies to the calendar year in which the service is paid. For example, if a service was provided in

December, but you paid for it in January of the current calendar year, it will apply to the current calendar year’s

reimbursement.

3. All reimbursement forms must be received no later than one year after the date you paid for the service.

•

Please note: Due to processing time, if you submit a reimbursement request late in the calendar year, MVP may need

to issue your reimbursement in the following calendar year. Depending on your plan’s specific wellness benefit, this

may cause you to meet or exceed the $600 threshold that would necessitate the filing of a Form 1099 with the IRS.

See “IRS Form 1099” on the front side of this form for more information.

4. You must pay for the service before submitting a request for reimbursement. For each reimbursement you are

requesting, you must attach:

• A copy of an itemized bill, statement, debit/credit card statement, or receipt that is pre-printed, stamped or

on company letterhead and includes the service provider’s name and address. (Balance forward/prior balance

statements are not acceptable).

• The documentation from the service provider must include the following information:

» The name of the provider;

» The type of service provided;

» The date the service was rendered (start date);

» Your out-of-pocket cost for the service, including date(s) of all payment(s); and

» The name of the person(s) receiving the service

5. Please allow 4-6 weeks for reimbursement. Reimbursement requests that are not submitted according to the above

mentioned guidelines will be returned for you to correct and re-submit. Reimbursement may be refused if the service

provider does not meet MVP’s benefit and quality standards.

6. Sign this form and return with required documentation to:

MVP Health Care, Wellness Benefit Reimbursement, 625 State Street, P.O. Box 2207, Schenectady, NY 12301

7. If you have questions about completing this form or your plan’s specific wellness benefit, contact the Customer Care

Center at the phone number on the back of your Member ID Card.

Examples of Services that Qualify for Reimbursement

TriVantage Wellness Benefit

Adult (age 18 and over) fitness classes and physical activities (including yoga sessions, kayak lessons, Tai Chi,

Pilates, martial arts), gym memberships, greens fees, ski lift tickets, personal training services. Plus, Healthy

Active Lifestyles Plan

Weight Support: select weight management programs —Weight Watchers®, Nutrisystem®, Jenny Craig®, TOPS

(Take Off Pounds Sensibly)—medical provider-based programs, or counseling with a registered dietician.

Kids’ (under age 19) fitness classes, physical activities and organized sports (examples include bowling

sports camps and teams, swimming lessons), as well as driver education. Plus, Healthy Weight Support:

Family Focus Plan

select weight management programs—Weight Watchers®, Nutrisystem®, Jenny Craig®, TOPS (Take Off

Pounds Sensibly)—medical provider-based programs, or counseling with a registered dietician.

Healthy Weight Support for members of any age: select weight management programs—Weight

Healthy Alternatives Plan

Watchers®, Nutrisystem®, Jenny Craig®, TOPS (Take Off Pounds Sensibly)—medical provider-based

programs, or counseling with a registered dietician.

What Does Not Qualify for Reimbursement

• Merchandise (e.g. attire, fitness equipment, fitness videos and publications, golf clubs, bicycles), equipment rentals (skis, bowling

shoes), or fees/expenses associated with motorized sports (e.g. snowmobiling)

• Food & dietary supplements (other than those purchased directly from a program listed as part of Healthy

Weight Support)

• Physical activities at country clubs (such as golf, swimming or skiing) that are not billed or itemized separately from membership fees

and/or dues; or strictly social memberships at country clubs

If you have a question about what qualifies for reimbursement or your plan’s specific wellness benefit, contact the Customer

Care Center at the phone number shown on the back of your Member ID Card.

(10/15) EFF 1/16

Trivantage Welness Benefit Reimbursement Form - Mvp Heath Care Page 2

Related Articles

Related forms

Related Categories