Get the free Lone Star Medical Reimbursement Account (MRA) Claim Form

This document is a claim form for members of the Lone Star Retirees Medical Reimbursement Account to submit unreimbursed medical expense claims.

How to fill out lone star medical reimbursement

How to fill out Lone Star Medical Reimbursement Account (MRA) Claim Form

1. Obtain the Lone Star Medical Reimbursement Account (MRA) Claim Form from your employer or the provided website.
2. Complete your personal information at the top section of the form, including your name, employee ID, and contact information.
3. Fill in the details of the expense, including the date of service, the type of service, and the amount being claimed.
4. Attach required documentation for each expense, such as receipts or explanation of benefits (EOB) statements.
5. Sign and date the form to certify that the information provided is accurate and complete.
6. Submit the completed form and attachments to the designated claims processing address or email.

Who needs Lone Star Medical Reimbursement Account (MRA) Claim Form?

1. Employees who participate in the Lone Star Medical Reimbursement Account (MRA) and incur qualified medical expenses.
2. Individuals seeking reimbursement for eligible healthcare costs incurred during the plan year.

People Also Ask about

What is the $800 reimbursement for Medicare?

Reimbursement Account for Basic Option Members Enrolled in Medicare Part A and Part B. Basic Option members enrolled in Medicare Part A and Part B are eligible to be reimbursed up to $800 per calendar year for their Medicare Part B premium payments. The account is used to reimburse member-paid Medicare Part B premiums.

How to submit a claim to Medicare Advantage?

If claim hasn't been filed on your behalf, contact your doctor, provider, or supplier, and ask them to file a claim for the service or supply you got. If you have contacted your doctor, provider, or supplier, and they haven't filed your claim, call us at 1-800-MEDICARE.

What is a MRA claim?

Medicare Reimbursement Account (MRA) Basic Option members who pay Medicare Part B premiums can be reimbursed up to $800 each year. You must submit proof of Medicare Part B premium payments through the online portal, EZ Receipts app or by fax or mail.

How to fill a medical reimbursement claim form?

List of documents to furnish Original hospital final bill. Original numbered receipts for payments made to the hospital. Complete breakup of the hospital bill. Original discharge summary. All original investigation reports along with prescriptions. All original medicine bills with relevant prescriptions.

For pdfFiller’s FAQs

What is Lone Star Medical Reimbursement Account (MRA) Claim Form?

The Lone Star Medical Reimbursement Account (MRA) Claim Form is a document used by employees to request reimbursement for eligible medical expenses incurred during the plan year.

Who is required to file Lone Star Medical Reimbursement Account (MRA) Claim Form?

Employees enrolled in the Lone Star Medical Reimbursement Account (MRA) program are required to file the claim form to receive reimbursement for qualifying medical expenses.

How to fill out Lone Star Medical Reimbursement Account (MRA) Claim Form?

To fill out the claim form, employees need to provide their personal information, details of the medical expenses, the amount requested for reimbursement, and attach any necessary receipts or documentation.

What is the purpose of Lone Star Medical Reimbursement Account (MRA) Claim Form?

The purpose of the claim form is to facilitate the reimbursement process for employees who have incurred out-of-pocket medical expenses that qualify under the MRA plan.

What information must be reported on Lone Star Medical Reimbursement Account (MRA) Claim Form?

The information that must be reported includes the employee's name, employee ID, the dates of service, description of the services received, the total amount paid, and any applicable documentation such as receipts or invoices.