Medical Reimbursement Checklist
Name | Company | Address |
[your name] | [your company name] | [your company address] |
This checklist ensures that all necessary information and documentation for a medical reimbursement claim are submitted correctly. The professional layout facilitates an efficient and systematic process for both claimants and office personnel.
Supporting Documents:
| YES | NO |
Medical Reports. | | |
Doctor's Note. | | |
Pharmacy Bills. | | |
Documentation for Reimbursement:
| YES | NO |
Attach Medical Reports. | | |
Include Doctor's Prescription Note. | | |
Pharmacy Receipts and Bills. | | |
Submission Protocol
| YES | NO |
Complete, verify, and sign the claim form. | | |
Attach a detailed breakdown of treatment costs. | | |
Ensure all supporting documents are attached. | | |
Submit the completed form to the insurance provider. | | |
Conduct follow-ups to track the claim status. | | |
Professional Verification
| YES | NO |
Patient's dependency on claimant verified. | | |
Essential Certification/AE form completed and countersigned. | | |
Discharge Certificate/Summary for inpatient treatment attached. | | |
Laboratory/Investigation and consultation fee breakdown provided. | | |
Special Nursing Certificate attached, if applicable. | | |
Office Use Only
| YES | NO |
Claim submitted within the stipulated 90-day period post-treatment. | | |
Detailed medication list provided in block capitals. | | |
Verification of claim form and documents for accuracy and completeness. | | |
Claimant's Signature: __________________________ Date: ___________
Office Representative's Signature: ______________ Date: ___________
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