Medical Claim Reimbursement Form

The Medical Claim Reimbursement Form includes information needed to review a Member's reimbursement request, preventing delays in the review process. It also acts as a Release of Information form which includes a signature in the case a member has not submitted any medical record(s) needed to complete the review.

Members can file a Medical Claim Reimbursement Form within ninety (90) days of the date of service if you received claims or bills from a provider for services with a balance due and/or to request reimbursement for services received that were not able to be billed to VHP 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

How to File a Medical Claim Reimbursement Form

Step 1: Fill out a Medical Claim Reimbursement Form

Step 2: Include original receipts, bills, invoices, and proof of payment.

Original receipt(s) including
- Name of patient;
- Name of doctor, hospital, or other provider;
- Date paid; and
- Amount paid.
Original itemized bill(s) or invoice(s) from provider including:
(If in the event of a foreign receipt, payment will be calculated based on dollar conversion rate at the time of service)
- Name of patient;
- Date(s) of service; and
- Nature of illness or injury - including medical and hospital billing code(s).
Proof of payment
- Other proof of payment, such as a copy of a cashed check or credit card receipt may be required.

Step 3: Mail or walk-in the completed Medical Claim Reimbursement Form with receipts, bills, invoices, and medical records within ninety (90) days of the date of service to:

Valley Health Plan
Attention: Member Services
2480 N. First Street, Suite 160
San Jose, CA 95131

Step 4: Additional forms may be required in order to process payments including W9 requirements. Upon approval of your request and completion of all payment requirements, a check will be mailed to you within forty-five (45) working days of the receipt of your request.

Medical Claim Reimbursement Form

How to File a Medical Claim Reimbursement Form

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