Fillable COVID-19 Testing Member Reimbursement Form Non-Medicare Advantage (Blue Cross Blue Shield of Michigan)

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COVID-19 Testing Member Reimbursement Form Non-Medicare Advantage (Blue Cross Blue Shield of Michigan)

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Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations
and independent licensees of the Blue Cross and Blue Shield Association.
W006259
COVID-19 Testing
Member Reimbursement Form –
Non-Medicare Advantage
Please use this form to request reimbursement for COVID-19 tests you have paid
for out of your own pocket. Submit one form per member. To be eligible for
reimbursement, your test must be authorized by the Food and Drug Administration,
you must provide documentation of the amount you paid (like a receipt) and follow
the guidelines below.
For at-home rapid diagnostic COVID-19 tests:
• There is a limit of 8 tests per member per month (based on the date of purchase).
• Testing for employment purposes is not covered and will not be reimbursed.
NOTE: If you bought the test prior to Jan. 15, 2022, you must also include
documentation that the test was ordered by a health care provider.
For all health care provider administered tests, additionally:
• You must provide documentation that the test was ordered or performed by a health care provider.
• The test was medically appropriate as determined by a licensed or authorized provider.
Reimbursement will not be approved without all the documentation listed above. All fields below must be completed to
enable processing of your request.
Subscriber Information
You can find your subscriber or member ID on your Blue Cross ID card.
Three character prefix Subscriber ID (Required) Group Number
Subscriber’s Last Name (Required) Subscriber’s First Name
Subscriber’s Street Address
City State Zip Code
Patient Information
Last Name First Name Date of Birth
Reason for the test (if health care provider ordered and authorized):
I was exposed to someone with COVID-19.
I had COVID-19 symptoms.
Other:
If you’re requesting reimbursement for an at-home test, please provide the following information:
Manufacturer of the test:
Where was test purchased (for example, Amazon.com)?
Date of purchase (MM/DD/YYYY): Reimbursement amount requested: $
How many tests in total were purchased?
Please indicate the number of tests in total, not number of boxes. For example, 1 box was purchased with 2 tests, indicate 2 tests in total.
By submitting this form, I attest that these at home tests are not being used for employment purposes.
If you’re requesting reimbursement for a test provided by a health care provider, please provide the following information:
Provider type (check one)
Provider’s office Laboratory or mobile lab Urgent care facility Pharmacy
Other:
Provider’s Name:
Provider’s Address:
Provider’s National Provider Identifier (NPI):
Date of service (MM/DD/YYYY): Cost of the test: $
I certify the above information is true, the enclosed material is correct and unaltered, and the expenses were incurred by the
patient listed above. False receipts or altering of this information will result in civil or criminal prosecution. I authorize the
release of any information as described below.
Signature Date Phone Number
We value your privacy. We won’t release any information about you unless you ask us to in writing or we must do so to process
or review your claim (by sharing with another insurance company, for example). We’ll tell you which information we released
and to whom, if you request it.
Please make sure you provide the following documents with this form:
• For at home tests, please make sure you provide a receipt indicating the amount you paid, date of purchase and where
you purchased the test.
• For tests provided by a health care provider, the original bill or claim for the services that includes:
− The laboratory or provider’s name and address
− The date of service
− The appropriate procedure and diagnosis codes
− The receipt indicating the amount you paid
• Keep copies of your original receipts for your files. We can’t return originals to you.
Mail this form to:
Blue Cross Blue Shield of Michigan
COVID Member Reimbursement
Imaging and Support Services
P.O. Box 32592
Detroit, MI 48233
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COVID-19 Testing Member Reimbursement Form Non-Medicare Advantage (Blue Cross Blue Shield of Michigan)

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Completed 14 January 2022

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