Cancel Claim Submission?
Are you sure you want to cancel your claim submission?
Cancel Claim Submission?
Opening this page will cancel the submission process and you will lose all information entered. Are you sure?
Oops...something went wrong.
An unexpected error has occurred. Please try again. If the error persists, please contact us.
Provider
Please enter the name of the provider who rendered the services.
Enter Claim Information
We're happy to process your claim for you. Please provide your claim information below. A separate claim should be submitted for each:
- Member
- Provider
- Claim Currency
At the end of this process you will receive a claim submission number.
All fields marked with an asterisk (*) are required.
We see you have a Global Care Card! That's great! If you used your Global Care Card to pay for the services you are claiming, you must upload your documentation to your pending transaction here.
Please note that continuing to file a claim for services paid for with the Global Care Card may result in overpayment to you. Any overpayments will be recovered by our payment collections team and card privileges may be revoked.
Member is required.
Provider is required.
Provider name allows only alphanumeric characters and ! # $ & ( ) " , . / : ; @ [] \ _ ` ‘ ’ “ ” + ' \ - – Ž Θ Ξ Ο Π Σ Ω
Provider Country is required.
Please enter a valid country name.
Provider Country allows only alphabetic characters and . - & ' ( ) , Å ô é
If your claim was incurred in the U.S., you may continue with your submission but you will not be able to track your status here. Please visit the U.S. claims page to do so.
Provider City is required.
Provider City allows only alphanumeric characters and . - & ; ' ,
Claim Nickname is required.
Claim Nickname allows only alphanumeric characters and . - & ; ',
Billed Amount is required.
Billed Amount must be a valid number.
Billed Amount must be greater than zero.
Claim Currency is required.
Please enter a valid currency.
Claim Currency allows only alphabetic characters and . - & '
Date of Service is required.
Date of Service cannot be a future date.
Please provide the member's diagnosis (for example: strep throat, back pain) or, if available, the ICD10 diagnosis code from your invoice.
150
Diagnosis is required.
Diagnosis allows only alphanumeric characters and . - & ; ' ,
Please provide a brief description of the treatment or services received (for example: office visit plus blood work).
250
Description of Treatment is required.
Description of Treatment allows only alphanumeric characters and . - & ; ' ,
Review Reimbursement Preference and Submit Claim
Edit Reimbursement Preference
Claim Information
Member
Provider
Provider Country
Provider City
Claim Nickname
Subscriber Name
Billed Amount
Claim Currency
Date of Service
Diagnosis
Description of Treatment
Files
Reimbursement Preference
This is your current reimbursement preference. If you change your reimbursement preference now, any claims currently being processed will be paid using that preference. Alternatively, you may elect a one-time reimbursement preference for this claim only.
*Choosing this option does not change your default preference for future claims.
Note: We allow dependents over the age of 18 to specify a one-time reimbursement for their claims.
Payee Name
Payee Name as it appears on your bank account.