Submitting Flexible Benefits Claim Forms
Dental and/or Vision
1. Before going to your first FY 2013 dental or vision appointment, print off the claim form. Claim forms are available at www.southdakotaflexbenefits.com.
Note: some providers have generic claim forms, which can be used as well. While the claim forms found on our site are available as a convenience, your claim will still be processed if a generic form is use as long as the member information is completed and the State of South Dakota is noted as the employer/policyholder of the plan.
2. Complete the member portion of the claim.
3. At your appointment, ask the provider to fill out the remaining portion or attach a copy of the dentist's bill/summary of services provided.
4. Determine who will receive the check from Ameritas, the Member or the Provider.
- Sign Line 13 on the claim form if you authorize payment to be made directly to the provider. If this line is not signed, payment will be sent to the member.
5. Talk to your provider about the two options for submitting claim forms.
- Provider sends the completed form to Ameritas. (Can be mailed in paper form, emailed, faxed or sent electronically by the provider.)
- Member sends the completed form to Ameritas. (Can be mailed in paper form, emailed to firstname.lastname@example.org , or faxed.)
Hospital Indemnity Plan (HIP)
The Hospital Indemnity Plan provides a daily benefit of $125 per day during eligible hospitalizations, regardless of coverage under other Plans.
1. Use your Health ID card when using the Hospital Indemnity Plan.
2. Print off the Hospital Indemnity claim form available at http://www.southdakotaflexbenefits.com, scroll over Hospital Indemnity, and choose HIP claim forms. The coverage is available for active employees and dependent family members.
3. Complete Parts B-D.
4. Sign and Date Part E.
5. Attach a copy of your Explanation of Benefits (EOB).
6. Mail the completed form and EOB to Reliance Standard.