PHP, Florida

Robert Heglar
AHF Provider

How to Ask for Reimbursement

Sometimes when you get medical care, you may need to pay the full cost right away, like if you get emergency or urgent care from a hospital, clinic or provider who is not in our network.  You can ask us to reimburse (pay you back).  It is your right to be reimbursed by our plan whenever you have paid for the cost of covered medical services.

There may be times when you get a bill from a provider for the full cost of medical care you have received.  You should send the bill to us instead of paying it.  We will look at the bill and decide whether the services should be covered.  If we decide they should be covered, we will pay the provider directly.

In either case, please contact Member Services.  You can also mail or fax the bill to us along with an explanation why you received the bill, your name and member ID (found on your member ID card).

By asking for reimbursement for care you received and paid for or asking us to pay a provider bill you received, you are asking for a coverage decision from us.  To make this coverage decision, we will check to see if the medical care you received and paid for or was billed for is a covered service.  We will also check to see if you followed all the rules for using your coverage for medical care.

If the medical care you paid for or was billed for is covered and you followed all the rules, we will send you payment within 60 calendar days after we receive your request.  Or, if you haven’t paid for the services, we will send the payment directly to the provider.

If the medical care is not covered, or you did not follow all the rules, we will not send payment.  Instead, we will send you a letter that says we will not pay for the services and reasons why.

If you do not agree with our decision, you can make an appeal.  We must give you our answer within 60 calendar days after we receive you appeal.

For more information about asking us to reimburse you for services you paid for or pay a provider bill you received, please see Chapter 9, Section 5 of the 2018 Evidence of Coverage and 2019 Evidence of Coverage, or contact Member Services.  You may contact Member Services to check on the status of your request for reimbursement.


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