Get Ma Mapfre Reimbursement Transmittal Claim Form 2018-2025

Filling out the MA MAPFRE Reimbursement Transmittal Claim Form online is a straightforward process that ensures your reimbursement requests are properly documented. This guide provides clear, step-by-step instructions to help you complete the form efficiently.

Follow the steps to successfully complete the claim form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the employee’s name in the designated field. This information is crucial for identifying the claim being submitted.
3. Next, input the contract number associated with your insurance plan. Ensure that this number is accurate to avoid delays in processing your claim.
4. Provide the name of the dependent for whom the claim is being filed, if applicable. If the claim is for the employee themselves, this section can be left blank.
5. Enter the employer’s name as it appears on company records. This helps verify your employment status.
6. In the policy number field, input your specific policy number. This is necessary for tracking your reimbursement request.
7. Fill out the diagnosis code as assigned by the healthcare provider. This code identifies the medical condition treated.
8. Specify the procedure code related to the service rendered. This is also provided by your healthcare provider.
9. Describe the service provided in detail. Include information that clarifies the treatment received.
10. If the claim is related to an accident, indicate this clearly. Provide details on how, when, and where the accident occurred.
11. Answer whether the claimant is currently insured with another health plan. If 'no', state the date coverage was terminated.
12. Provide the account owner's name, routing number, and account number if you wish to receive reimbursements via electronic fund transfer. Specify the bank name and type of account (checking or savings).
13. Enter your contact information including home and cell phone numbers, as well as an email address for correspondence.
14. If applicable, send a void check as an attachment to facilitate ACH transfers, although this is optional.
15. Sign the form in the designated area to confirm the accuracy of the information provided.
16. Finally, review all information for accuracy. Save changes to your document, and then download, print, or share the completed form as needed.

Complete your MA MAPFRE Reimbursement Transmittal Claim Form online today to ensure prompt processing of your claim.