Form BCRF-1 "Masshealth Member Pharmacy Mail Order Expense Reimbursement Form" - Massachusetts

What Is Form BCRF-1?

This is a legal form that was released by the Massachusetts MassHealth - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2021;
  • The latest edition provided by the Massachusetts MassHealth;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form BCRF-1 by clicking the link below or browse more documents and templates provided by the Massachusetts Masshealth.

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Download Form BCRF-1 "Masshealth Member Pharmacy Mail Order Expense Reimbursement Form" - Massachusetts

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MassHealth Member Pharmacy Mail Order
Expense Reimbursement Form
MassHealth may be able to reimburse members for their out-of-pocket mail order pharmacy expenses for Mass-
Health covered services when a MassHealth member is seeking to fill a mail order pharmacy prescription(s) and is
required to pay the mail order pharmacy expense (including co-insurance, co-payments, and deductibles) up front
to the provider in compliance with their private insurance coverage policy. This enhanced benefit allows members
to fill their mail order prescriptions quickly at no extra cost to them.
To ensure your request is received and processed in a timely manner, please include all information requested
on this form and return along with an Explanation of Benefits (available through your insurance company) for the
dates of service where you were charged an out-of-pocket expense. If there is incomplete documentation, this
could delay the verification of your out-of-pocket expenses, which could cause a delay in issuing payments. The
Benefit Coordination and Recovery Program (BCR) will review your mail order out-of-pocket pharmacy expense
reimbursement request and will contact you (or parent\guardian) if there are questions. Once reviewed, approved
and processed, the MassHealth reimbursement will be disbursed within 21 calendar days. Questions about the
status of the reimbursement request can be directed to the BCR Customer Service line at (800) 462-1120.
Note: It is recommended that the reimbursement request be submitted within one year of the date of service for
any out-of-pocket expenses to ensure timely processing of your request. You may submit up to 5 dates of
service per reimbursement request.
Reimbursement Checklist:
The prescription was filled by a required out-of-state mail order provider, not a retail pharmacy.
The service qualifies for Pharmacy Out-of-Pocket Mail Order reimbursement.
The member is an eligible MassHealth member on the date(s) of service.
The documentation submitted agrees with the requested refund amount.
The refund request contains sufficient proof of payment, i.e., cancelled check, credit card statement.
An Explanation of Benefit (EOB) from the Mail Order Pharmacy is attached to support the refund request.
Shipping and handling expenses are not to be included in the requested reimbursement amount.
Definitions:
1. Name
Your name as it appears on your MassHealth ID card
2. MassHealth Member ID Number
12-digit member ID number on your MassHealth ID card
3. Date of Birth
MM/DD/YYYY
4. Address
Complete address to send the reimbursement check
Preferred daytime contact number we can use to reach you if we
5. Phone Number
have questions
6. Date of Service
Date that you received the service from the mail order pharmacy
7. Type of Service Received
What service did you receive from the mail order pharmacy (needs
to be a MassHealth covered pharmacy service)
8. Mail Order Pharmacy Name
Name of the Mail Order Pharmacy
9. Mail Oder Pharmacy Address
Address for Mail Order Pharmacy
10. Mail Order Pharmacy Phone Number Phone number for Mail Order Pharmacy
11. Member Out-of-Pocket Expense
The amount of copay/deductible/coinsurance listed on the EOB as
member responsibility or the amount you paid for the service received
Phone (800) 462-1120 | Fax (617) 886-8134
MassHealth Member Pharmacy Mail Order
Expense Reimbursement Form
MassHealth may be able to reimburse members for their out-of-pocket mail order pharmacy expenses for Mass-
Health covered services when a MassHealth member is seeking to fill a mail order pharmacy prescription(s) and is
required to pay the mail order pharmacy expense (including co-insurance, co-payments, and deductibles) up front
to the provider in compliance with their private insurance coverage policy. This enhanced benefit allows members
to fill their mail order prescriptions quickly at no extra cost to them.
To ensure your request is received and processed in a timely manner, please include all information requested
on this form and return along with an Explanation of Benefits (available through your insurance company) for the
dates of service where you were charged an out-of-pocket expense. If there is incomplete documentation, this
could delay the verification of your out-of-pocket expenses, which could cause a delay in issuing payments. The
Benefit Coordination and Recovery Program (BCR) will review your mail order out-of-pocket pharmacy expense
reimbursement request and will contact you (or parent\guardian) if there are questions. Once reviewed, approved
and processed, the MassHealth reimbursement will be disbursed within 21 calendar days. Questions about the
status of the reimbursement request can be directed to the BCR Customer Service line at (800) 462-1120.
Note: It is recommended that the reimbursement request be submitted within one year of the date of service for
any out-of-pocket expenses to ensure timely processing of your request. You may submit up to 5 dates of
service per reimbursement request.
Reimbursement Checklist:
The prescription was filled by a required out-of-state mail order provider, not a retail pharmacy.
The service qualifies for Pharmacy Out-of-Pocket Mail Order reimbursement.
The member is an eligible MassHealth member on the date(s) of service.
The documentation submitted agrees with the requested refund amount.
The refund request contains sufficient proof of payment, i.e., cancelled check, credit card statement.
An Explanation of Benefit (EOB) from the Mail Order Pharmacy is attached to support the refund request.
Shipping and handling expenses are not to be included in the requested reimbursement amount.
Definitions:
1. Name
Your name as it appears on your MassHealth ID card
2. MassHealth Member ID Number
12-digit member ID number on your MassHealth ID card
3. Date of Birth
MM/DD/YYYY
4. Address
Complete address to send the reimbursement check
Preferred daytime contact number we can use to reach you if we
5. Phone Number
have questions
6. Date of Service
Date that you received the service from the mail order pharmacy
7. Type of Service Received
What service did you receive from the mail order pharmacy (needs
to be a MassHealth covered pharmacy service)
8. Mail Order Pharmacy Name
Name of the Mail Order Pharmacy
9. Mail Oder Pharmacy Address
Address for Mail Order Pharmacy
10. Mail Order Pharmacy Phone Number Phone number for Mail Order Pharmacy
11. Member Out-of-Pocket Expense
The amount of copay/deductible/coinsurance listed on the EOB as
member responsibility or the amount you paid for the service received
Phone (800) 462-1120 | Fax (617) 886-8134
MassHealth Member Pharmacy Mail Order
Expense Reimbursement Form
12. EOB
Explanation of Benefits — Obtained through your insurance company
or Mail Order Pharmacy. Including this with the reimbursement form
will help speed up processing time.
Documentation that the member paid the mail order expense
13. Proof of Payment
out-of-pocket to the Mail Order Pharmacy such as the cancelled
check, credit card statement, etc.
Instructions:
1. Complete this form in its entirety and sign below.
2. Provide the Explanation of Benefits (EOB) for the services received.
3. Provide Supporting Payment Information such as cancelled check or credit card statement.
4. Return completed form in one of the following ways:
a. Mail: Benefit Coordination and Recovery Program, 529 Main St, Suite 302, Charlestown, MA 02129
b. Fax: (617) 886-8134 (Subject Line: Benefit Coordination and Recovery Refund Request)
Part 1: Member & Policyholder Information
1. Member Name: ________________________________________________________________________________
2. MassHealth Member ID Number: _________________________ 3. Date of Birth: ________________________
4. Member Address (Street, City, State, ZIP): __________________________________________________________
5. Member Phone Number: ________________________________________________________________________
6. Insurance Policy Number: ________________________________________________________________________
7. Policy Holder Name: ____________________________________________________________________________
8. Relationship of Policy Holder to Member (Self, Parent, etc.): ___________________________________________
Part 2: Information about Service Received
1. Date(s) of Service (DOS), Member Expense ($), and Prescription Name – Limit five per reimbursement request:
DOS 1
DOS 2
DOS 3
DOS 4
DOS 5
Date of Service
Expense ($)
Prescription
Name
2. Mail Order Pharmacy Name: _____________________________________________________________________
3. Mail Order Pharmacy Address: ___________________________________________________________________
Phone (800) 462-1120 | Fax (617) 886-8134
MassHealth Member Pharmacy Mail Order
Expense Reimbursement Form
Part 3: Payment Information
Payment should be sent to:
 Member listed in Part 1
 Member Parent/Guardian
1. Member Address (Street, City, State, ZIP): __________________________________________________________
2. Attention to Member or Parent/Guardian Name: _____________________________________________________
3. Receiver of Reimbursement (provide one of the following):
• MassHealth ID #: _____________________________________________________________________________
Or if not a MassHealth member:
• SSN #: ______________________________________________________________________________________
Signature:
I certify under pains and penalty of perjury that what is stated on this form is correct and complete to the best
of my knowledge.
Member or Parent/Guardian Signature: _______________________________________
Date: ________________
Phone (800) 462-1120 | Fax (617) 886-8134
BCRF-1-0421
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