3790 (01/2017)
www.wageworks.com
Tips For Claim Submission
• An eligible dependent is defined as a spouse, qualifying child, or
qualifying relative.
- A qualifying child is defined as a dependent child up to age 26
or any age if permanently disabled.
- A qualifying relative is someone who resides with you for more
than half of the year.
- Qualifying children and relatives must not provide more than
half of his/her own support.
• For information to claim orthodontia expenses, refer to the guide
located at: https://www.wageworks.com/employees/support-
center/important-forms.aspx.
• For a complete list of eligible expenses specific to your plan, log
in to your account at www.wageworks.com and select “Eligible
Expense” from the left side of the screen. Only submit claims for
eligible expenses.
• A letter of medical necessity is required for any expense listed as
“Yes (Letter)” on the eligible expense list to establish medical
necessity. Cosmetic surgery or procedures, e.g., teeth whitening,
are not eligible expenses unless deemed as medically necessary
by a licensed physician. A letter of medical necessity form can be
obtained at: https://www.wageworks.com/employees/support-
center/important-forms.aspx.
Tip for Over-the-Counter Expenses
• A prescription is required for any over-the-counter expense listed
as “Yes (Rx)” on the eligible expense list. As a result of the Health
Care Reform Law, in addition to the required detailed receipt,
an actual prescription written by a doctor (on a prescription pad
or form) dated on or before the date the expense was incurred
is required to verify that the over-the-counter medicine is
prescribed for a known medical condition.
Tips For Documentation
• Ensure that the documentation is legible.
• Cancelled or copies of checks and credit card receipts do not
contain all 6 required pieces of information needed to approve
your expense, and are not acceptable for submission.
• Explanation of Benefits (EOBs) are recommended, especially if
your insurance covered a portion of the expense.
• The use of a highlighter causes items to not be legible on the
documentation; highlighter use is not recommended.
• Send only photocopies of your claim form and documentation—
keep the originals for your records if submitting via US Mail.
• Your provider may sign the form confirming the date of services,
charges, and other service or product information in lieu of
providing separate documentation or other proof of service.
Tips For Faxing
• Do not use a cover page when faxing the claim form and
documentation.
• Submit only claims for your own account.
Tips for Viewing Claim Status
• Please allow 2 business days from receipt of your claim for
processing.
• You will be notified via email of the status of your claim if we
have a valid email address on file (to update your email address,
please log in to your account at www.wageworks.com and select
“Profile” in the upper right corner of the screen).
HEALTHCARE ACCOUNT
How to File a Claim for Approval
Instructions to fill out this form:
• Complete ALL account holder
information.
• Provide your employer name without
abbreviation.
• Use your documentation to complete
each section of the form, including the
following:
Provider Name
Service Date(s)
Patient Name and Relationship to
Account Holder
Type of Service
Patient Responsibility
Provider Signature is not required,
but can replace need for other proof
of service
SMI TH JOHN
JONES GRAPH I CS
5421 10063
Mercy Hospital
Dr. Mark Johnson, M.D.
Mercy Pharmacy
010517
010517
011417
011417
John Smith
Mary Smith
2 5 0 0
1 0 70
Claim Filing Options:
• File claim online: Log in to your account at www.wageworks.com to submit your claim electronically.
• File claim via fax or mail: Claim details may be entered online and a completed form may be printed and faxed or mailed
with documentation. Fax: 877-353-9236 , US Mail: CLAIMS ADMINISTRATOR, P.O. Box 14053, Lexington, KY, 40512
3790 (01/2017)
www.wageworks.com
• File claim online: Join the growing majority of participants who submit their claim
online for faster service. Log in to your account at www.wageworks.com to file
your claim electronically and upload your documentation.
• File claim via fax or mail: Claim forms may also be filed either via fax or US Mail
and sent to the following locations: Fax: 877-353-9236,
US Mail: CLAIMS ADMINISTRATOR, P.O. Box 14053, Lexington, KY, 40512
• Claim processing time: Claims will be processed within 2 business days after receipt of the
form. You may check the status of your claim by logging in to your account at www.wageworks.com.
CERTIFICATION AND AUTHORIZATION: I certify that the information on this form is accurate and complete. I am requesting reimbursement for eligible deductible expenses
incurred by myself or an eligible dependent while I was a participant in the plan. (Patient & Relationship is assumed to be Self unless otherwise indicated.) I have already
received these products and services and confirm that by requesting reimbursement here that I have not and will not seek reimbursement of this expense from any other
plan or party. If I am covered under more than one healthcare account, reimbursement will be made according to the payment order determined by those plans and as stated
on the website. Use of this service indicates my acceptance of the WageWorks User Agreement at www.wageworks.com (available upon registration; enter username and
password or click on Employee Registration link).
HEALTHCARE ACCOUNT
Pay Me Back Claim Form
ACCOUNT HOLDER:
Last Name First Name
Employer Name
ID Code* Zip Code
* ID Code is the last 4 digits of your Social Security number, your Employee ID number or other reference
number assigned by your employer. Please check the enrollment instructions provided by your program
sponsor for more information about your ID Code.
PROVIDER NAME
SERVICE DATES
(Start and End Dates)
(MM/DD/YY)
PATIENT NAME, RELATIONSHIP TO ACCOUNT HOLDER
AND TYPE OF SERVICE
OUT-OF-POCKET
COST
Patient Name: ___________________________________________________________
Relationship to Account Holder:
Signature of Provider:
(Replaces the need for other proof of service.)
Patient Name: ___________________________________________________________
Relationship to Account Holder:
Signature of Provider:
(Replaces the need for other proof of service.)
Patient Name: ___________________________________________________________
Relationship to Account Holder:
Signature of Provider:
(Replaces the need for other proof of service.)
Patient Name: ___________________________________________________________
Relationship to Account Holder:
Signature of Provider:
(Replaces the need for other proof of service.)
More expenses? Please complete another form. CLAIM FORM TOTAL:
Self
Spouse
Qualifying Child
Qualifying Relative
Other: _________________
Type of Service:
Rx Lab
Dental Vision
Psych/Therapy Hospital
Ortho X-Ray
Chiro OTC
Co-payment Oce Visit
Other ___________________________
$
.
,
$
.
,
Self
Spouse
Qualifying Child
Qualifying Relative
Other: _________________
Type of Service:
Rx Lab
Dental Vision
Psych/Therapy Hospital
Ortho X-Ray
Chiro OTC
Co-payment Oce Visit
Other ___________________________
$
.
,
Self
Spouse
Qualifying Child
Qualifying Relative
Other: _________________
Type of Service:
Rx Lab
Dental Vision
Psych/Therapy Hospital
Ortho X-Ray
Chiro OTC
Co-payment Oce Visit
Other ___________________________
$
.
,
Self
Spouse
Qualifying Child
Qualifying Relative
Other: _________________
Type of Service:
Rx Lab
Dental Vision
Psych/Therapy Hospital
Ortho X-Ray
Chiro OTC
Co-payment Oce Visit
Other ___________________________
$
.
,
