1
G
A
B
Please review the instructions on the
reverse side of this form before completing.
Health Benefits Claim Form
1.
PATIENT A
INFORMATION
ENROLLMENT CODE IDENTIFICATION NUMBER
R
B
PATIENT’S NAME (First, Middle Initial and Last)
C
PATIENT’S DAT E OF BIRTH
D
PATIENT’S SEX
E
NAME OF ENROLLEE OR POLICY HOLDER (First, Middle Initial and Last)
F
DATE OF BIRTH
Month/Day/Year
Male Female
PATIENT’S RELATIONSHIP
TO ENROLLEE
Self Spouse Child
If the patients last name is different from the enrollees, please attach a statement explaining the relationship.
H ENROLLEE’S CURRENT ADDRESS (Street, City, State and ZIP Code) CHECK IF NEW ADDRESS
I
EMAIL ADDRESS
PLEASE COMPLETE INFORMATION BELOW ONLY IF IT HAS CHANGED SINCE YOU LAST GAVE IT TO US. IF NO CHANGES, GO TO #5.
2.
OTHER HEALTH
Is the patient covered by additional health insurance through an employer, a group such as a professional organization, or any other
INSURANCE
group health insurance, including other Blue Cross and/or Blue Shield Coverage?
If yes, please complete this section.
Yes No
A
NAME AND ADDRESS OF INSURING COMPANY (Street, City, State and ZIP Code)
B
EFFECTIVE DATE
TERMINATION DATE
Month/Day/Year
Month/Day/Year
C
NAME OF POLICY HOLDER (First, Middle Initial and Last)
AND HIS/HER EMPLOYER
D
DATE OF BIRTH
Month/Day/Year
E
IDENTIFICATION NUMBER (Include all letters
and numbers)
3.
MEDICARE
PLEASE COMPLETE THIS SECTION ON MEDICARE REGARDLESS OF THE PATIENT’S AGE
If you are covered by a Medicare HMO/Prepaid Plan, please leave Sections A and B Blank
A
MEDICARE PART A
(Hospital Insurance)
If yes, effective date
Month/Day/Year
Yes
No
B
MEDICARE PART B
(Medical Insurance)
If yes, effective date
Month/Day/Year
Yes
No
C
MEDICARE HMO/
PREPAID PLAN
If yes, effective date
Month/Day/Year
Yes
No
D
If the patient is eligible for Medicare due to End-Stage
Renal Disease, please indicate the beginning date of
renal treatment or transplant.
Month/Day/Year
4.
EMPLOYMENT
Is the patient
presently employed?
Yes
No
If the patient is retired from the Federal Government, but still employed, please
complete the following:
NAME AND ADDRESS OF COMPANY OR GOVERNMENT AGENCY (Street, City, State, and ZIP Code)
5.
DIAGNOSIS
Describe illness, injury or symptoms requiring treatment. If illness, injury or symptoms are related to an accident,
please complete A, B and C.
A
DATE OF ACCIDENT
Month/Day/Year
B
TIME
AM
PM
C
LOCATION
At Home Motor vehicle accident Was the accident caused by someone else?
At Work If so, what state Yes No Other
Other Please explain
6.
CHARGES Please list below those charges that you are claiming for benefits. Use a separate line for each type of service or provider.
PLEASE ATTACH ITEMIZED BILLS
NAME OF PROVIDER MAKING CHARGE
(Doctor, Hospital, etc. Two or more bills from the same
provider may be entered on one line if they are for the
same type of service.)
DESCRIPTION OF CHARGE
(Office Visits, Therapy from Mental
Conditions, etc.)
DATE OF SERVICE OR PURCHASE
(If there is only one date, show it under “FROM”.)
FROM TO CHARGE
I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above. Authorization is hereby given to any provider of
service, which participated in any way in my care, to release to the Blue Cross and/or Blue Shield Plan any medical information which they deem necessary to adjudicate this claim.
7.
SIGNATURE
Signature of Enrollee or Patient Date Daytime telephone number
Failure to sign this claim form may delay processing.
including area code
4F1-19049 - F Rev. 03/18
Month/Day/Year
CLEAR FORM
Date and type of service or supply.
Diagnosis.
Charge for each service or supply.
Provider Identification Number
INSTRUCTIONS
Pl
ease complete a separate claim form for each patient
, and remember to file all claims by December 31 of the calendar year after the one in which the
covered care or service was provided. Since most of the information requested on this form is self-explanatory, we did not include specific instructions for each item. However,
please complete each item. If the information requested does not apply to the patient, indicate N/A (NOT APPLICABLE).
Special care should be taken when completing the following items:
1A and 2E These spaces are for the Blue Cross and Blue Shield Service Benefit Plan Enrollment Code and Identification Number (Item 1A) and other Health Insurance
Identification Number (Item 2E). When completing these items, please ensure that these numbers and letters are exactly as they appear on your identification
card(s).
3A, B and C Medicare covers persons age 65 and over and persons who qualify because of disabling conditions such as End-Stage Renal Disease.
THEREFORE,
PLEASE COMPLETE ITEMS 3A AND B REGARDLESS OF THE PATIENT’S AGE.
Item C should be completed if applicable.
ITEMIZED BILLS FOR COVERED SERVICES OR SUPPLIES MUST BE ATTACHED TO THIS FORM AND MUST INCLUDE THE
FOLLOWING:
Personal itemizations, cash register receipts and cancelled checks are not acceptable. Since itemized bills cannot be returned,
please be sure to make copies for your records. In addition,
bills for home nursing care must show the professional status, such as R. N. (Registered
Nurse). Bills for all drugs and medicines dispensed by a physician, the outpatient department of a hospital or any other non-retail-pharmacy provider must show the name
of each drug or medicine.
Joseph Warowes
102 West 35th Street
Healthville, U.S.A.
Dayton Pendridge, M.D.
101 Fourth Street
Healthville, U.S.A.
NAME OF THE PERSON
OR ORGANIZATION
PROVIDING THE SERVICES
OR SUPPLIES
NAME OF THE PATIENT
RECEIVING THE SERVICES
OR SUPPLIES
For Professional Services Rendered To:
Virginia E. Warowes
$ XXX
DATE EACH SERVICE
OR SUPPLY WAS PROVIDED
DESCRIPTION OF THE SERVICES
OR SUPPLIES PROVIDED
1/22/94 Examination
Chest X Ray
CBC
2/5/94 Office Visit
PLEASE CROSS OUT THOSE CHARGES THAT WERE
INCLUDED ON A PREVIOUS CLAIM
XXX
XXX
XXX
CHARGE FOR EACH
RETAIL PHARMACY PROGRAM
Prescription drugs and supplies purchased on and after January 1, 1994, from a Preferred retail pharmacy in the U.S. or Puerto Rico will be filed for the member. Preferred
pharmacies will not file claims for drugs requiring prior approval. Claims for drugs not filed by a retail pharmacy must be submitted to the Retail Pharmacy Program by the
member on the
Retail Prescription Drug Claim Form
. This form can be downloaded from www.fepblue.org.
You can also call 1-800-624-5060 for more information, claim forms and customer service assistance. The claim form provides detailed instructions for submission of the
form and should be mailed to: Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057.
SPECIAL SERVICES
Certain services such as physical, speech and occupational therapy, durable medical equipment, home nursing care and dental care resulting from an accidental injury may
require additional information along with this claim form. Call your local Blue Cross and/or Blue Shield Plan before submitting your claim for such services; they will send
you additional forms, if needed.
FOR PATIENTS COVERED BY MEDICARE
When the patient is covered by Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) and incurs expenses which are covered by Medicare, if
Medicare is primary (it pays first), your claim must be submitted to Medicare first
(See Note Below)
. After the Medicare payment has been made, a claim for the expenses
not paid by Medicare, to include a copy of your
Itemized bill,
can be submitted to your local Blue Cross and/or Blue Shield Plan, along with the appropriate forms from
Medicare. For retail pharmacy prescription drug expenses, see the instructions above.
1.
For Medicare Part A inpatient services, attach the “Explanation of Benefits” form from Medicare.
2.
For Medicare Part B services, attach the Explanation of Medicare Benefits” and/or the “Your Record of Part B Medicare Benefits Used” form furnished by the Medicare
Carrier or Intermediary. Also, a copy of your itemized bill should be sent along with the Medicare Information.
NOTE: If the following conditions are met, the Blue Cross and Blue Shield Service Benefit Plan is primary (it pays first).
·If you are 65 or over and employed by the Federal Government and have Medicare Part A (or Parts A and B);
·If you or your spouse are employed by the Federal Government and your covered spouse is 65 or over and has Medicare Part A (or Parts A and B);
·If the patient (you or a covered family member) is under 65, eligible for Medicare benefits only because of End-Stage Renal Disease (ESRD) and is within the first 18 months
of eligibility to receive Medicare Part A benefits; or
·
If the patient (you or a covered family member) is under age 65 and eligible for Medicare solely on the basis of disability, and you are employed by the Federal Government
FOR PATIENTS COVERED BY OTHER HEALTH INSURANCE
When submitting charges for services or supplies that have been partially paid by other group health insurance,
attach a copy of the Notice of Payment or
Explanation of Payment from the other health care insurer.
THIS COMPLETED FORM,TOGETHER WITH ITEMIZED BILLS AND SUPPORTING MATERIAL, SHOULD BE SUBMITTED TOYOUR
LOCAL BLUE CROSS AND/OR BLUE SHIELD PLAN. THE MAILING ADDRESS FOR YOUR LOCAL PLAN CAN BE LOCATED
ON FEPBLUE.ORG BY USING THE FOLLOWING LINK: WWW.FEPBLUE.ORG/CONTACT
The Blue Cross and Blue Shield Service Benefit Plan
4F1-19049 - F Rev. 03/18
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