Get (see Instructions On Reverse Side) - Metracomp

This guide provides clear and systematic instructions for completing the (See Instructions On Reverse Side) - MetraComp online form. By following these steps, you will ensure your Medicare Part B Premium Reimbursement request is filled out accurately and completely.

Follow the steps to successfully complete your reimbursement request.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete the participant information section. Ensure you print your name clearly in the format of Last, First, MI. Include your MHBP ID number, daytime phone number, and address, including city, state, and ZIP code.
3. Fill out the Medicare Part B Premium Reimbursement request section. List the premium month(s) for which you are requesting reimbursement and provide the associated dollar amounts for each month.
4. Attach the required supporting documentation. You must include either the Notice of Annuity Adjustment or a copy of your bill or payment coupon. Ensure these documents include your Medicare Part B carrier name, your name, the premium amount, and coverage dates.
5. Sign and date the form. Reimbursement claims cannot be honored without the participant’s signature, so ensure this is completed.
6. Submit the completed form and attachments. You can mail your documents to Coventry Consumer Choice at the provided address or fax them to the specified number. Keep the originals and obtain a fax receipt for your records.
7. If you have questions regarding your claim, contact MHBP Customer Service at the provided phone number for assistance.
8. Note that electronic fund transfers will be made directly into your designated bank account. Keep in mind that reimbursement is not guaranteed to be tax-free.

Start filling out your (See Instructions On Reverse Side) - MetraComp online document now to secure your reimbursement.