What documentation should accompany the Claim Reimbursement Form for each type of claim?

Dr. Office Visit:

• A copy of the bill, OR

• An EOB (Explanation of Benefits), OR

• Office notes

Note: Routine care is not reimbursable under the GAP Plan.

  Out-Patient Hospital: • A copy of the hospital bill

  In-Patient Hospital:

• A copy of the EOB

• A copy of the hospital bill

Note:  There is no limit to the number of hospitalization benefits payable. Each hospitalization benefit is payable on its own. There is a limit for the out-patient benefit if the treatment is for the same condition within a 90-day period.