INSTRUCTIONS FOR FILING A CLAIM
IMPORTANT
:
Use this form for all medical, pharmacy, dental, and vision services covered by Regence. If your policy utilizes a vendor for
pharmacy, dental or vision services, contact the vendor for any necessary forms or instructions for ling your claim.
If the services were rendered on a cruise ship or are related to a prescriptions purchase made outside of the United States,
you may proceed using this form.
All other service types rendered outside of the United States will need to be led on the International Claim Form and
submitted according to the instructions provided via www.bcbsglobalcore.com.
You only need to ll out this form if your health care professional isn’t ling the claim for you. Your health care professional can
still le the claim for you if they are out-of-network with your policy; however, they are not required to do so.
Payment is made directly to contracting health care professionals. We only send payment to you when the health care
professional is out of network and there is evidence that you have paid in full for the services rendered.
If services are a result of an accident or injury, complete the Accident/Injury section of the claim form. If there is another party
that may be responsible to pay for these services, such as homeowner’s or auto insurance, please contact an agent in our
Other Party Liability department at 877-633-7877 to assist you further. You may still continue with your claim submission.
If you have Medicare or other insurance coverage that is not already on le with Regence, or if it has changed or terminated,
you will need to contact Regence to update your account to ensure your claim processes correctly and timely.
FILING REQUIREMENTS:
Complete a separate claim form for each covered family member.
Enclose itemized receipts and make copies for your records. Receipts must include the following:
Patient’s Name
Date(s) of Service (mm/dd/yyyy)
Procedure Code(s). This is usually a 5-digit number that is the description of services/products provided
Diagnosis Code(s) - ICD Format - The reason for your medical treatment
Health care professional’s Full Name, Credentials, Address, Phone Number and Tax ID Number and National Provider
Identier (NPI)
Total charge for each service rendered
If the patient has Medicare or other health insurance coverage, and that other insurance coverage is primary and Regence is
secondary, we need an Explanation of Benets (EOB) for this service from the other insurance company when you send the
completed form and itemized bill.
**Failure to submit required information may cause a delay in the processing of your claim.
FORM PD020-ID Page 3 of 3 (E. 10/18) v2