Claim Form: FSA Reimbursement Form

Form #R450-2059

Audience: Members

Format: Form

Share with members requesting reimbursement from FSAs.

Updated: 4/24

Claim Form: Health Reimbursement Account Reimbursement Form

Form #LH-2056-WEMP

Audience: Members

Format: Form

Share with members requesting reimbursement from health reimbursement accounts.

Updated: 4/24

Commuter Benefits (FSA/HRA benefit card) - WEMP version

Form #LH-1672-WEMP

Audience: Members

Format: Flyer

Share with members to show how to use FSA/HRA benefit card to pay for commuter expenses

Updated: 10/25

Frequently Asked Questions - Members

Form #LH-3089-WEMP

Audience: Members

Format: Flyer

Share with members to answer frequently asked questions.

Updated: 12/23

Know Your Medical FSA Eligible and Ineligible Expenses Brochure

Form #LH-389-WEMP

Audience: Members

Format: Brochure

Share with members to give members a broad overview of what they can and cannot pay for using funds in their FSA.

Updated: 4/24

Maternity Management Member Flyer

Form #LH-2656-WS

Audience: Members

Format: Flyer

This flyer encourages members to enroll in Wellstar's maternity management program. Includes an overview of the program and and how it works.

Updated: 3/25

Members FSA-HRA FAQ (with FSA/HRA benefit card) Flyer

Form #LH-1677-WEMP

Audience: Members

Format: Flyer

Share with members to answer common questions that come up about their FSA and how to use their card.

Updated: 4/24

Three Reasons to Schedule Your Annual Exam Member Flyer

Form #LH-2645_WS-WEMP

Audience: Members

Format: Flyer

Provide to members to help educate them about why they should regularly see their PCP.

Updated: 12/23

Three Reasons to See Your PCP Member Flyer

Form #LH-2645-WS

Audience: Members

Format: Flyer

Provide to members to help educate them about why they should regularly see their PCP.

Updated: 5/24

Understanding Subrogation

Form #LH-3303-WS

Audience: Members

Format: Flyer

Provides members with a brief overview of the subrogation process and how to navigate claims.

Updated: 2/25

Claim Form: FSA Reimbursement Form (WEMP)

Form ##LH-2059-WEMP

Audience: Members

Format: Form

Share with members requesting reimbursement from FSAs.

Updated: 4/24

Request for Direct Deposit and Electronic EOB Form (ACH Form)

Form #LH-3463

Audience: Members

Format: Form

Use this form to collect member information that signs them up for direct deposit and electronic EOBs.

Updated: 11/25

Claim Form: Annualized Dependent Care Reimbursement Form

Form #LH-2055-WEMP

Audience: Members

Format: Form

Share with members requesting reimbursement from dependent care accounts.

Updated: 4/24

Claim Form: FSA Direct Deposit Form

Form #LH-2058-WS

Audience: Members

Format: Form

Share with members requesting direct deposit to FSAs.

Updated: 4/24

Perspecta Provider Search User Guide - Members

Form #LH-3239-WS-Member

Audience: Members

Format: Brochure

Share with members to provide step-by-step instructions for how to access and use the Provider Search Module.

Updated: 7/24

Predetermination Request Form

Form #LH-3226-WS

Audience: Members, Providers

Format: Form

Use this form to determine if a proposed treatment or service is covered.

Updated: 5/24

Members FSA-HRA FAQ (with FSA/HRA benefit card) Flyer (WS)

Form #LH-1677-WS

Audience: Members

Format: Flyer

Share with members to answer common questions that come up about their FSA and how to use their card.

Updated: 4/24

A Client's Guide To Registering on wellstarhealthplan.org

Form #LH-2138

Audience: Employers/Clients

Format: Brochure

Share with clients to walk them through how to register for the portal

Updated: 1/24

Medical Specialty Drug Management Prior Authorization Member Flyer

Form #LH-2765-WS

Audience: Members

Format: Flyer

Provide to members to help them understand the prior authorization process with Archimedes.

Updated: 4/24

Member Mobile App Flyer

Form #R450-1162_WS

Audience: Members

Format: Flyer

Share with members to inform them about the capabilities of Wellstar Health Plan's mobile app and encourage them to download.

Updated: 2/26