Get Out-of-network Reimbursement Form - Advantica

Filing a reimbursement request can be straightforward if you follow the right steps. This guide will provide clear, step-by-step instructions to help you accurately complete the Out-of-network Reimbursement Form for Advantica.

Follow the steps to successfully complete your reimbursement form

1. Press the ‘Get Form’ button to access the reimbursement form and open it for editing.
2. Fill in the Group Name/ID field with your specific group information as provided by your employer or plan administrator.
3. Enter the Name of Subscriber in the designated field, which should be the person who holds the insurance plan.
4. Provide the Subscriber ID Number as listed on your insurance card to ensure accurate processing.
5. Input the Name of Individual Receiving Services, which could be yourself or a dependent covered under the plan.
6. Include the Date of Birth of the individual receiving the services. Make sure to format it correctly for processing.
7. Check the appropriate services received by marking the corresponding boxes. Confirm your plan details to determine available coverage for each service.
8. After completing the form, compile your itemized receipt and attach it to the form.
9. Submit the completed form along with your receipt to the following address: Advantica, Attn: Claims Department, 3290 Pine Orchard Lane, Suite C, Ellicott City, MD 21042. Ensure that you allow at least thirty days for processing.
10. Finally, consider saving the changes you made, downloading a copy, or printing the form for your records.

Complete your Out-of-network Reimbursement Form online today for a smooth reimbursement process.