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 200
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.

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