Citi Benefits Handbook
How to File a Claim
Claims must be submitted in order to receive reimbursement for charges incurred under the Plans. Many times, the claim is submitted electronically to the claims administrator without your intervention needed. However, you may be required to manually submit a claim for expenses to be paid or approved for reimbursement. Keep in mind that you cannot submit medical, dental, vision, HCSA, LPSA, or DCSA claims for services or expenses incurred prior to the effective date of your coverage.
Listed below are the forms needed to claim benefits that may not be reimbursed automatically or paid directly. Claims should be sent to the Claims Administrators as detailed under "Claims Administrators" in the Administrative Information section. If you do not receive benefits to which you believe you are entitled, see the applicable "Claims and Appeals" subsection in the section that describes each plan at handbook.citibenefitsonline.com, available from the Citi intranet and the Internet. No password is required.
Name of Plan
Name/form number and when to use the form
How to obtain a form
Aetna
  • ChoicePlan 500 (CP500)
  • High Deductible Health Plan (HDHP)
Aetna Medical Benefits Request form
Use the form to file a claim for covered out-of-network expenses.
Visit Forms and Claims on Citi Benefits Online at www.citibenefitsonline.com
Or
Visit Your Benefits Resources™ through TotalComp@Citi at www.totalcomponline.com
Anthem BlueCross BlueShield
  • CP500
  • HDHP
Anthem BlueCross BlueShield Claim form
Use the form to file a claim for covered out-of-network expenses.
Oxford Freedom Direct Plan
Oxford Health Plans Claim form
Use the form to file a claim for covered out-of-network expenses.
HMOs
Call your HMO for any claim-filing information. Use the contact information on the back of your ID card or visit For More Information.
Express Scripts
(Prescription drug coverage for CP500, HDHP, and Oxford PPO)
Express Scripts Prescription Drug Claim form
Use the form to file a claim for covered out-of-network expenses.
Visit Forms and Claims on Citi Benefits Online at www.citibenefitsonline.com
Or
Visit Your Benefits Resources™ through TotalComp@Citi at www.totalcomponline.com
Or
Call Express Scripts at 1 (800) 227-8338 or visit
www.express-scripts.com
MetLife Dental PDP
MetLife Dental Claim form
Use the form to file a claim for covered dental expenses.
Visit Forms and Claims on Citi Benefits Online at www.citibenefitsonline.com
Cigna DHMO
There are no claim forms required with the Cigna Dental HMO plan. When your Dental Patient Charge Schedule lists a copay, pay that amount to the dentist directly after you receive care.
Vision Plan
Aetna Vision Claim form
Use the form to file a claim for covered out-of-network expenses.
Visit Forms and Claims on Citi Benefits Online at www.citibenefitsonline.com
Or
Health Care Spending Account (HCSA)
HCSA/LPSA Claim form
Use the form to submit eligible health care claims for reimbursement if you do not use the Your Spending Accounts™ Card.
Visit the ConnectYourCare (CYC) website through TotalComp@Citi at www.totalcomponline.com
Or
Visit Forms and Claims on Citi Benefits Online at www.citibenefitsonline.com
Limited Purpose Health Care Spending Account (LPSA)
HCSA/LPSA Claim form
Use the form to submit eligible vision, dental, and/or preventive care health care claims for reimbursement.
Dependent Day Care Spending Account (DCSA)
DCSA Claim form
Use the form to submit eligible dependent care claims for reimbursement.
Transportation Reimbursement Incentive Program (TRIP)
TRIP Claim form
Note: With the exception of the Parking Cash Reimbursement Option (CRO). CRO claims must be filed within 12 months from the date of service.
All claims for benefits and pertinent supporting documents must be filed by these deadlines:
  • Medical, dental, and vision claims must be filed within two years of the date of service. If you participate in an HMO, call your HMO for its claim-filing deadlines.
  • Prescription drug claims must be filed within one year of the date of service.
  • HCSA, LPSA, and DCSA claims must be filed and resolved (i.e. all substantiating documentation should be submitted) by June30 following the year in which the expense was incurred.
  • TRIP Parking Cash Reimbursement Option (CRO) claims must be filed by June 30 following the year in which the expense was incurred.