Citi Benefits Handbook
How to File a Claim
Health Advocate can help: call 1 (866) 449-9933. For more information about Health Advocate, visit Live Well at Citi.
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.
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Name of Plan
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Name/Form Number and When to Use the Form
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How to Obtain a Form
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Aetna
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Aetna Medical Benefits Request form
Use the form to file a claim for covered out-of-network expenses.
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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
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Anthem BlueCross BlueShield
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Anthem BlueCross BlueShield Claim form
Use the form to file a claim for covered out-of-network expenses.
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HMOs
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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.
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CVS Caremark
(Prescription drug coverage for CP and HDHP)
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CVS Caremark Prescription Drug Claim form
Use the form to file a claim for covered out-of-network expenses.
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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
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MetLife Dental PDP
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MetLife Dental Claim form
Use the form to file a claim for covered dental expenses.
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Visit Forms and Claims on Citi Benefits Online at www.citibenefits.com
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Cigna DHMO
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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.
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Vision Plan
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Aetna Vision Claim form
Use the form to file a claim for covered out-of-network expenses.
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Visit Forms and Claims on Citi Benefits Online at www.citibenefits.com
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Visit www.aetnavision.com
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Health Care Spending Account (HCSA)
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HCSA/LPSA Claim form
Use the form to submit eligible health care claims for reimbursement if you do not use the Optum Financial Payment Card
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Visit the Optum Financial website through My Total Compensation and Benefits at www.totalcomponline.com
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Visit Forms and Claims on Citi Benefits Online at www.citibenefits.commmc
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Limited Purpose Health Care Spending Account (LPSA)
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HCSA/LPSA Claim form
Use the form to submit eligible vision, dental, and/or preventive care health care claims for reimbursement.
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Dependent Day Care Spending Account (DCSA)
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DCSA Claim form
Use the form to submit eligible dependent care claims for reimbursement.
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Transportation Reimbursement Incentive Program (TRIP)
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TRIP Claim form
Note: Except for 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.
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Supplemental Medical Plans
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The Aetna Simplified Claims Experience™ is available online on the My Aetna Supplemental app, or member portal at Myaetnasupplemental.com. You can also view your coverage and sign up for direct deposit.
If you are also an Aetna medical member (enrolled in the In-Network Only Plan, Choice Plan, High Deductible Plans with HSA) you won't have to provide any medical documents to file your claim. If you're not enrolled in an Aetna plan, the process is the same, but you will be prompted to provide medical documents, like an itemized bill.
Call Aetna Voluntary Member Services with any questions or for a paper claim form at 1 (800) 607-3366 (TTY: 711), Monday through Friday, 8 AM to 6 PM.
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MetLife Legal Plans
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MetLife Legal Plans Out-of-Network Claim Form
Note: You do not need to file a claim when you use an in-network attorney.
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Contact MetLife Legal Plans at 1 (800) 821-6400 to request an out-of-network claim form. You will be reimbursed according to a set fee schedule.
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All claims for benefits and pertinent supporting documents must be filed by these deadlines:
- Medical, dental and vision claims must be filed within one year 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.
- Supplemental medical plan claims must be filed within three years from the date of service.
- TRIP Parking Cash Reimbursement Option (CRO) claims must be filed by June 30 following the year in which the expense was incurred.