Fillable MEMBER REIMBURSEMENT FORM (University of Utah)

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MEMBER REIMBURSEMENT FORM (University of Utah)

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MEMBER REIMBURSEMENT FORM
Thank you for choosing Regence for your health care coverage.
To submit a claim online, go to the “Member Dashboard / Claims” section and select the yellow “Submit a Claim” button.
For services abroad please utilize the International Claim Form located at www.bcbsglobalcore.com.
To mail or fax your claim, please review the ling instructions located at the end of this form before you begin for helpful information
regarding how to complete your claim so that it will process quickly and accurately.
Contact customer service using the toll-free number on your Regence Member Identication card if you have any questions, or
communicate with the Live Help team on regence.com for on-line assistance. We are happy to serve you.
MEMBER INFORMATION
Patient’s Name (Last, First, M.I.) Patient’s Date of Birth (mm/dd/yyyy) Patient’s Sex
Male
Female
Policyholder’s Name (Last, First, M.I.) Patient’s Relationship to Policyholder
Self
Spouse
Dependent
Policyholder’s Address City State ZIP Code Telephone Number
Patient’s ID Number (3 letters followed by 9 numbers) Group Name Group Number
Does the patient have coverage from any other health plan including Medicare?
No. Please skip to Claim Details.
Yes. Please attach the Explanation of Benets (EOB) statement from the primary plan with this claim, and complete the
following information.
Name of Other Health Plan ID Number / Policy Number of Other
Health Plan
Telephone Number of Other Health
Plan
CLAIM DETAILS
Name of Provider Address where services were rendered Date(s) of Service (mm/dd/yyyy)
Diagnosis (describe illness and symptoms requiring treatment): Total Charges
Briey describe the service(s) you received:
Have the charges been paid in full?
No.
Yes.
In what setting were these services performed?
Inpatient Hospital
Outpatient Hospital
Oce/Clinic
Surgery Center
Skilled Nursing Facility
Home
Other
If applicable, list the contact information of the physician that prescribed/ordered these services:
Name Address Telephone Number
INTERNATIONAL SERVICES
Is this claim for expenses incurred outside the U.S.A.?
No. Please skip to Accident/Injury.
Yes. Please refer to instructions above for submitting an International Claim.
FORM PD020-UT Page 1 of 3 (E. 10/18) v2
(mm/dd/yyyy)
State
xxxxx-xxxx
(xxx) xxx-xxxx
(xxx) xxx-xxxx
(xxx) xxx-xxxx
ACCIDENT / INJURY
Is this claim due to an accidental injury?
No. Please skip to Signature.
Yes. Please complete this section.
Date of accident (mm/dd/yyyy) Where did the accident occur?
Home
Work
School
Auto
Other
How did the accident happen?
Description of injury:
Please Note: If there is another party that may be responsible to pay for these services, such as homeowner’s or auto insurance,
please nish submitting your claim then contact an agent in our Other Party Liability department at 877-633-7877 to assist you
further.
SIGNATURE
To be accepted, this form must be fully completed (as appropriate to the claim being submitted) signed, and have an
itemized bill attached.
Patient Signature (or legal guardian if patient cannot legally consent to services) Relationship to Patient Date (mm/dd/yyyy)
Self
Other
Please Note: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, nes, and denial of insurance benets.
I certify that the above statements are correct and hereby authorize any physician, hospital, employer, union, insurance company, or
prepayment organization to supply my employer and its agents any information required in connection with this claim. A photocopy
of this authorization shall be as valid as the original.
Signature (Subscriber or Patient) Date
Thank you for choosing Regence as your health plan administrator. We recommend that you make copies of everything that is
submitted for your personal records.
Mail this claim to:
Regence BlueCross BlueShield of Utah
PO Box 1106
Lewiston, Idaho 83501
Or Fax claim to: (888) 606-6582
FORM PD020-UT Page 2 of 3 (E. 10/18) v2
(mm/dd/yyyy)
(mm/dd/yyyy)
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
Identier (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 Benets (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-UT Page 3 of 3 (E. 10/18) v2
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MEMBER REIMBURSEMENT FORM (University of Utah)

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Completed 21 April 2022

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