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How to Claim

How to Submit a MiCare Claim

A copy of the MiCare Plan Claim Reimbursement Form can be downloaded from our Forms and Downloads page. Meanwhile, please note the requirements below when submitting a claim.

Required Documents for Reimbursement Claims

The following documents are required by the Plan in order to facilitate the review and process of reimbursement claims.

1. Pharmacy
  • Copy of Doctor’s Prescription (with name of patient, dosage of meds prescribed)
  • Copy of Payment Receipt or any document as a proof of payment such as credit card receipt and copy of check issued.
  • For Drugs Purchased in Guam, Hawaii and US Mainland, Pharmacy Label is accepted provided the name of drug; dosage; name of prescribing doctor is indicated.
2. Office Visit
  • Copy of Doctor’s Clinical Summary
  • Itemized Billing Statement
  • Copy of Payment Receipt or any document as a proof of payment such as credit card receipt or copy of check issued.
3. Hospital In-Patient
  • Itemized Billing Statement
  • Copy of Doctor’s Medical Summary
  • Copy of Payment Receipt or any document as a proof of payment such as credit card receipt or copy of check issued.
4. Dental
  • Dental Summary or Itemized Dental Billing
  • Copy of Payment Receipt or any document as a proof of payment such as credit card receipt or copy of check issued.
5. Optical Claim
  • Copy of Prescription from the Optical Clinic
  • Copy of Payment Receipt or any document as a proof of payment such as credit card receipt or copy of check issued.
NOTE: All claims must be submitted within 1 year from date of service. Incomplete claims and claims submitted after 1 year will not be accepted. MiCare will not request documents from providers. A detailed English translation must be included with all non-English claims.