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
  • Choice Plan 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 at Citi Benefits Online at www.citibenefits.com
Or
Visit Your Benefits Resources™ through My Total Compensation and Benefits 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.
HMOs
Call your HMO for any claim-filing information. Use the contact information on the back of your ID card or see the For More Information section.
CVS Caremark
(Prescription drug coverage for CP500 and HDHP)
CVS Caremark 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.citibenefits.com
Or
Visit Your Benefits Resources™ through My Total Compensation and Benefits at www.totalcomponline.com
Or
Call CVS Caremark at 1 (844) 214-6601 or visit www.caremark.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.citibenefits.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.citibenefits.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 ConnectYourCare Payment Card
Visit the ConnectYourCare (CYC) website through My Total Compensation and Benefits at www.totalcomponline.com
Or
Visit Forms and Claims on Citi Benefits Online at www.citibenefits.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), all other TRIP CRO claims must be filed within 12 months from the date of service. Parking Cash Reimbursement Option (CRO) claims must be filed by June 30 following the year in which the expense was incurred.
MetLife Legal Plans
MetLife Legal Plans Out-of-Network Claim Form
Note: You do not need to file a claim when you use an in-network attorney.
Contact MetLife Legal Plans at (800) 821-6400 to request an out-of-network claim form. You will be reimbursed according to a set fee schedule.
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 June 30 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.
Important COVID-19-Related Changes that Extend Claims and Appeals Deadlines
On May 4, 2020, the U.S. Departments of Labor and the Treasury (the Agencies) issue guidance that temporarily extends the deadlines in place for certain benefit changes and processes associated with election, notification, payment and claims/appeals in connection with the Coronavirus disease of 2019, which was deemed a national emergency on March 1, 2020 (the National Emergency). To protect individuals from losing benefit, the Agencies extended deadlines that might have been missed during the National Emergency. The temporary extension of the deadlines was initially set to expire 60 days after the end of the National Emergency. The Agencies have revised their guidance to provide that your extended deadline will end on the earlier of one year from your original deadline or your original time limit after the end of the National Emergency as described above (Agencies' deadline).
For HCSA, LPSA, and DCSA claims: The deadline to submit any claims for expenses incurred during 2019 has been recalculated to allow an additional four months to submit claims for reimbursement from the end of the Agencies’ deadline.
For more information, contact the Claims Administrators as detailed under "Claims Administrators" in the Administrative Information section, or call the Citi Benefits Center via ConnectOne at 1 (800) 881-3938 for additional help. From the Benefits menu, select the appropriate option. See the For More Information section for detailed instructions, including TDD and international assistance.