Catamaran Direct Member Reimbursement Form PDF Details

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

QuestionAnswer
Form NameCatamaran Direct Member Reimbursement Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesreimbursement claim catamaran form, Catamaran, NPI, catamaran insurance reimbursement

Form Preview Example

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):

 

Pharmacy

Fill

Drug Name

 

Physician

 

Days

Amount

 

 

 

Rx #

NDC Number

Quantity

NABP/NPI #

Date

(including strength)

DEA/NPI #

Supply

Paid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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:

1-888-341-8583

 

Member did not have the Catamaran prescription drug card with them

Mail to:

Member did not receive the Catamaran prescription drug card before the time of purchase

Catamaran

Vacation supply

 

Claim was rejected at the pharmacy

Direct Member Reimbursement

Claim consideration for Coordination of Benefits (secondary coverage)

P.O. Box 1069

Out-of-network purchase

Rockville, MD 20849-1069

Other; please attach a detailed explanation to be considered for reimbursement

 

 

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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