Valley Health Plan’s (VHP) "Medical Claim Reimbursement Form" is designed to include information that VHP will need to review the reimbursement request, thus preventing delays in the review process. It also acts as a Release of Information form which includes a signature in the case that medical records need to be acquired to complete the review, if not already submitted by the member.
Please fill out the Medical Claim Reimbursement Form if you received claims or bills from providers for services with a balance due and/or to request reimbursement for services received that were not able to be billed to Valley Health Plan and had to be paid out of pocket such as:
- Urgent Care & Emergency Services when out of the Valley Health Plan (VHP) network.
- Prescription Drugs for the above stated or when in network and VHP network pharmacies are closed.
For each case, Valley Health Plan will review the request along with supporting documentation including a "Medical Claim Reimbursement Form" submitted by the member.
- Requests should be received within ninety (90) days of the date of service.
- Upon approval of your request, a check will be mailed to you within forty-five (45) working days of the receipt of your request.
How To File A Medical Claim Reimbursement Form
Medical Claim Reimbursement Form - English
Cómo presentar un Formulario de Reembolso por un Reclamo médico
Medical Claim Reimbursement Form - Spanish
Thủ Tục Nộp Đơn Yêu Cầu Bồi Hoàn Y Phí
Medical Claim Reimbursement Form - Vietnamese