Fillable MEMBER CLAIM FORM Do not file prescription drugs (North Carolina Wesleyan College)

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MEMBER CLAIM FORM Do not file prescription drugs (North Carolina Wesleyan College)

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Filing Requirements:
Any claim filed without the required documentation listed above will be returned.
• Visit bcbsnc.com for prescription drug, dental and international claim forms, or call the toll-free number on your ID card.
• Complete a separate claim form for each covered family member.
• Enclose itemized receipts and make copies for your records. See Section IV for required information.
• Do not file a claim if the provider is filing for the same services.
• Attach Explanation of Benefits if these services are covered by another insurance policy.
• Claims must be filed within 18 months from the date services were received, or they will be denied.
• Please see Section VI for mailing information.
MEMBER CLAIM FORM
Do not file prescription drugs on this form. Use blue or black ink to complete.
An independent licensee of the Blue Cross and Blue Shield Association. ®,
SM
Marks of the Blue Cross and Blue Shield Association.
SM1
Mark of Blue Cross and Blue Shield of North Carolina. BE236, 12/07
SECTION I: Patient Information Please enter the subscriber number from your ID card.
SECTION III: Other Insurance Information
Please complete the information below if the patient is covered by another health insurance policy.
PLEASE NOTE: If your other insurance or Medicare policy is primary, you must attach a copy of the Explanation
of Benefits from that insurer. Your claim cannot be processed without this information.
SECTION II: Mailing Information Please check here if address has changed.
Please complete the information below if the patient is covered by Medicare:
Subscriber
Number:
Does the patient
have other insurance?
Patient’s Last Name:
Subscriber Name:
Address (Line 1):
Address (Line 2):
City: State: ZIP Code:
Other health insurance
company name:
Medicare health insurance
claim number:
Other policy
number:
Other policy holder’s
employer name:
Other policy
holder’s name:
First Name:
Male
Female
Middle Initial:
2 digits preceding patient’s
name (see ID card)
Begin with
4-letter prefix
Date
of Birth:
Relationship
to Subscriber:
Sex:
Yes
No
Is patient
eligible for:
Part A
Part B
Part A and B
Self
Spouse
Child
Other:
NC
Please indicate where services were rendered if not in North Carolina:
SECTION IV: Services and Supplies To Be Considered For Reimbursement
These may include ambulance services, medical appliances, diabetic supplies, glasses and/or contact lenses or out-of-network services.
BCBSNC requires that procedure codes and diagnosis codes on the itemized receipt be supplied by the provider of
the service.
Claims or itemized receipts received without the information below will be RETURNED.
SECTION V: Private Duty Nursing Enclose a copy of your receipts for these services.
Date of Service
(MM/DD/YY)
Diagnosis Codes or Symptoms You
Sought Treatment For
ChargeProcedure Codes or Description of Service/Supplies
DID YOU REMEMBER TO:
• Use blue or black ink to complete the form?
• Attach the Explanation of Benefits, if applicable?
• Attach itemized receipts?
• Provide your signature below?
• Keep a copy of this form and your receipts?
MAIL THIS FORM, ITEMIZED RECEIPTS AND
EXPLANATION OF BENEFITS (if applicable) TO:
Blue Cross and Blue Shield of North Carolina
P.O. Box 35
Durham, NC 27702
SECTION VI: Mailing Information
Date of Service
(MM/DD/YY)
Indicate
RN, LPN or CNA
Hours
Worked
ChargeName of Nurse License Number
Signature: Date:
Daytime
Phone
Number:
I certify that the information on this form is correct and the expenses incurred were necessary for the services filed.
01-05-07 Office Visit Cold and Flu Symptoms $54.00
EXAMPLE:
03-10-07 Ms. Jane M. Doe LPN 123456 8 $160.00
EXAMPLE:
Country: Currency Used:
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MEMBER CLAIM FORM Do not file prescription drugs (North Carolina Wesleyan College)

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Completed 23 July 2020

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