Pay Me Back Claim Form - Medicare Reimbursement Account (Mra)
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Pay Me Back Claim Form
INSTRUCTIONS
(DO NOT fax these instructions with your claim)
PLEASE READ THIS BEFORE SUBMITTING YOUR CLAIM FORM
The Internal Revenue Service (IRS) requires you to provide documents to verify your
reimbursement. Your documents must show that you paid for a Medicare Part B premium. At
a minimum, the document(s) must show:
a) the date of coverage or expense
b) the name of the person who incurred the expense
c) the name of your insurance carrier (Blue Cross and Blue Shield Service Benefit Plan)
d) the type of expense (Medicare Part B premiums)
e) proof of premium payment
Tips for Completing the MRA Pay Me Back Claim Form
1. Print or write legibly.
2. Complete a separate form for your dependent or spouse.
3. Make sure you sign the form. If your Power of Attorney signs, please make sure he or
she signs the form in the following format “John Smith, Attorney in Fact for Jane Smith.”
Make sure the Power of Attorney is either on file or submitted with the first claim.
4. You should complete the account holder name section with your first and last n ame.
5. Submit copies of your Cost of Living Adjustment (COLA) Statements or other documents
providing proof that you pay Medicare Part B premiums with your claim form. Keep the
original documents for your records. If your claim is incomplete, you must resubmit the
claim form and proof of Medicare Part B premium. Send legible copies of your
documents.
WW-BCBS-FEP-MRA-RT-PMB-INST (Dec 2017)
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