Valley Health Plan’s (VHP) “Medical Claim Reimbursement Form” should be completed for the following individuals:

• Members who are requesting reimbursement for services received that were not able to be billed to Valley Health Plan and had to be paid out of pocket; and/or
• Members who receive claims/bills from providers for services with a balance due. 

Examples of these services are:

• 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.

The form is designed to include information that VHP will need to review the request, thus preventing delays in the review process.  It also acts as a Release of Information form which includes a signature in the case that medical records need to be acquired to complete the review, if not already submitted by the member.  

For each case, Valley Health Plan will review the request along with supporting documentation including a “Medical Claim Reimbursement Form” submitted by the member. 

Requests should be received within ninety (90) days of the date of service.  Upon approval of your request, a check will be mailed to you within forty-five (45) working days of the receipt of your request.   

See the below “Medical Claim Reimbursement Form” attachment. It includes the form and how to file it.