All Claim Reimbursements

Please use the form attached below as a cover sheet to submit ALL reimbursement claims
(including NFP & Gianna Family Care reimbursements) to Edison Health Solutions (EHS).

Please submit the form & reimbursement claim on your Edison portal:

If your physician does not bill insurance, please ask the physician for a superbill. That superbill should contain all of the information required below so that EHS can process the claim on your behalf.

To avoid any possible delays, make sure to provide your Employee Contact Number on the form in case EHS needs to follow up with you for additional information.

Note: EHS cannot reimburse from a credit card receipt without the accompanying bill from the
Provider.

Information Required for Reimbursement:

• Provider Name
• Provider Address
• Provider Tax Id#
• Diagnosis Code
• Procedure or HCPC code
• Total Billed Charges
• Amount Paid by the Employee