Get Benicomp Claim

Filling out the Benicomp Claim form online is a straightforward process that ensures you provide all necessary information for your medical reimbursement claims. This guide will walk you through each section of the form to help you complete it accurately and efficiently.

Follow the steps to successfully complete the Benicomp Claim form

1. Press the ‘Get Form’ button to access the Benicomp Claim form and open it in your preferred editor.
2. Begin by filling in the 'Group Name' and 'Group #' fields. These details are essential for identifying your specific insurance plan.
3. In the 'Insured’s Name' section, input the full name of the person who holds the insurance policy. Next, provide their birthdate, email address, and the last four digits of their Social Security Number.
4. Fill in the 'Claimant’s Name' field with the name of the person submitting the claim. Include their birthdate and relationship to the insured, selecting from the options provided.
5. For each service incurred, complete the following details: (1) Provider of Services, (2) Date Incurred, (3) Amount of Expense, (4) Amount Eligible for Payment Under Plan of Benefit, and (5) Amount Eligible for Payment under Plan (Column 3 minus Column 4). Repeat this for each service you are claiming.
6. At the bottom of the form, input the total amount being submitted for reimbursement.
7. Review the certification statement and sign it, ensuring that all information provided is accurate. Include the date of signing.
8. Once all sections are complete, you can save your changes, download a copy, print the form, or share it as needed.

Complete and submit your Benicomp Claim online today to ensure you receive your medical reimbursement efficiently.