As a Catamaran Direct member, you may be eligible for reimbursement of select out-of-pocket expenses. The purpose of this form is to provide our members with a mechanism to request reimbursement for qualified expenses incurred while receiving medical care. Please review the guidelines below to determine if your expense qualifies, and complete the form accordingly. Thank you for choosing Catamaran Direct as your healthcare provider! The Catamaran Direct Member Reimbursement Form is now available! As a member, you may be eligible for reimbursement of select out-of-pocket expenses. The purpose of this form is to provide our members with a mechanism to request reimbursement for qualified expenses incurred while receiving medical care. Please review the guidelines below to determine if your expense qualifies
Question | Answer |
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Form Name | Catamaran Direct Member Reimbursement Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | reimbursement claim catamaran form, Catamaran, NPI, catamaran insurance reimbursement |
DIRECT MEMBER REIMBURSEMENT FORM
Please attach a detailed receipt from the pharmacy, including all of the following information. If this information is not on the receipt, please have the pharmacist complete and sign this form and attach proof of payment. Without the required information, Catamaran will not be able to process your claim.
PRESCRIPTION FILLED FOR (Patient Name):DATE OF BIRTH (Patient DOB): PLAN PARTICIPANT IDENTIFICATION NUMBER (Printed on prescription card):
MAILING ADDRESS:
PLAN NAME (Employer or Group Name):
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Pharmacy |
Fill |
Drug Name |
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Physician |
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Days |
Amount |
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Rx # |
NDC Number |
Quantity |
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NABP/NPI # |
Date |
(including strength) |
DEA/NPI # |
Supply |
Paid |
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PHARMACIST SIGNATURE:PHARMACY PHONE NUMBER:
*PHARMACIST SIGNATURE IS REQUIRED WHEN A DETAILED RECEIPT IS NOT PROVIDED.
All reimbursements are subject to plan terms and conditions and may be reduced from the submitted amounts based on plan cost and copayments. Any reimbursement due will be refunded to the policyholder.
Please check one of the following reimbursement request reasons: |
Fax to: |
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Member did not have the Catamaran prescription drug card with them |
Mail to: |
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Member did not receive the Catamaran prescription drug card before the time of purchase |
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Catamaran |
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Vacation supply |
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Claim was rejected at the pharmacy |
Direct Member Reimbursement |
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Claim consideration for Coordination of Benefits (secondary coverage) |
P.O. Box 1069 |
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Rockville, MD |
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Other; please attach a detailed explanation to be considered for reimbursement |
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Any person who knowingly and willfully presents a false or fraudulent claim for payment for a loss or benefit or who knowingly and willfully
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
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