Member Reimbursement FAQs

Where is the form?

The reimbursement form can be downloaded here (PDF).

How do I submit?

At this time, the dental reimbursement form can only be received by mail. Please submit the form and all documentation to:

Envolve Benefit Options
Claims Department-Member Reimbursement
P.O. Box 23768
Tampa, FL 33623-3768

What should I put in this field?

  • Patient Member ID# : the number found on the front of the health plan member ID card. If there is a dash with more numbers at the end, include all of the numbers. 
  • Name : Last and First names and Middle Initial of patient who received services. 
  • Date of Birth : month (2 digits), day (2 digits), year (4 digits). Include newborn's date of birth in the same box as the parent's.
  • Address : Use residential address; no PO box, please.
  • Telephone : Include your area code.
  • Other Insurance Coverage : if you have more than one dental insurance that applies, select yes.

What is this form used for?

  • This form is used to ask for reimbursement of out of pocket expenses for eligible dental care performed by a provider who is not in the Envolve network of providers.
  • Only members with out-of-network benefit coverage will be considered for reimbursement.

What is my responsibility?

  • Copayments, deductibles, coinsurance, and non-covered services will be patient responsibility. 
  • If you receive care from an out-of-network provider and the provider bills more than the Usual, Reasonable, and Customary charge, the member will be responsible (i.e. balance billed) for the sum of the coinsurance amount and any amount that is over the Usual, Reasonable and Customary charge.

How much will I receive?

  • Actual payment for covered service will be paid at the appropriate level according to your plan benefits and you may be billed for the difference between Envolve allowed amount and the providers billed charges. 

What happens next?

  • After processing your claims, you will receive an Explanation of Benefits (EOB).
  • The EOB explains the charges applied to your deductible (the fixed dollar amount you pay for covered services before the insurer starts to make payments) and any charges you may owe the provider.
  • Please keep your EOB on file in case you need it in the future.

What if I need help completing this form?

Call the Member Services number on your health plan member ID card.