Submit a separate claim form for each family member.
Complete the top section of the claim form including the employee's name, employee's birth date, employee's social security number, patient's name, patient's birth date, and relationship to employee.
Complete the middle section of the claim form:
"Type of Service" Place a check in the appropriate column of reimbursement (medical, dental, vision, etc.).
"Provider Name" Place the name of the provider in the middle column. For prescriptions use Rx.
"Date of Service" Complete the date of service (the date the service was performed, not when the bill was paid).
"Amount Eligible for Payment" Calculate the amount eligible for reimbursement after other insurance payments, provider discounts, etc. and enter the amount.
"Total" Complete the total amount of reimbursement requested.
For medical expenses, the explanation of benefits from the base medical plan must be submitted.
For all other expenses, supporting documentation must include itemized statements (bills) for
verification of each expense. Canceled checks, credit card receipts, previous balance, or balance
forward bills are not accepted. Exec-U-Care must have a copy of the itemized bill from the
provider which includes the patient's name, provider's name, date of service, diagnosis or
description of services provided, the charge, and an indication from the base plan as to what they
will or will not cover.
Attach backup documentation for each expense (itemized bills, Rx statements, etc.).
Documentation must be submitted on an 8 ½ x 11 sheet of paper. Please do not use tape, glue, or staples.
Each claim form is limited to 10 items and must contain supporting documentation for each line.
The documentation must be itemized and cannot state "see attached". If the documentation requires
multiple claim forms, submit each form and documentation as separate claims.
Make a photocopy of the claim form and all supporting documents to send to Exec-U-Care.
Keep the originals for your records.
Please have a corporate officer within the company sign the bottom portion of the claim form.
Claims received without a corporate officer's signature will be returned.
Date and sign the claim form.
Mail to Exec-U-Care, PO Box 4540, Iowa City, IA 52244-4540.
The Claim Form can be found here, or in the menus.
Exec-U-Care is underwritten by The Lincoln National Life Insurance Company, 8801 Indian Hills Drive, Omaha, NE 68114. 800-552-1213 http://www.LincolnFinancial.com/
