OW TO USE THIS FORM
sually, all providers of health care will bill us for services to you and your enrolled dependents. This is the preferred procedure. You are not
bothered with claim forms and we often need more details than are ordinarily provided on bills to patients.
ometimes, a physician may not bill us, or an ambulance company, for example, may send the bill directly to you. In either instance, we have
no way of knowing about your claim. This Member Claim Form was developed to notify us of any covered health service for which we have not
already been billed. Please read the following instructions about how to report Health Care Services.
e are happy to serve you.
PATIENT INFORMATION SUBSCRIBER INFORMATION (on Anthem Blue Cross Card)
Use this section to identify the patient and subscriber. Some of this information may be found on your Anthem Blue Cross card.
HEALTH CARE SERVICES: Use this section to report any COVERED health service which has not already been reported to this Anthem Blue Cross
Plan by the provider of service (the physician, clinical, ambulance company, private duty nurse, etc.) Attach itemized bill or photocopy. Please be
sure that duplicate bills are not submitted.
ATE OF SERVICE PROVIDER OF SERVICE SERVICE RENDERED
ILLNESS OR DIAGNOSIS TOTAL
(Mo/Day/Yr) (Name of Doctor, Lab, Amb. Co., etc.) (Office Visit, X-ray, etc.)
5/9/08 John Wang, M.D. Office Visit Bronchitis $35.00
5/9/08 Pat Fogarty, M.D. X-ray Strain $57.00
THE FOLLOWING INFORMATION MUST ALSO BE INCLUDED ON BILLS FOR THESE ITEMS:
REGISTERED AND LICENSED VOCATIONAL NURSES:
Hours and dates of service
Location of service (residence or name of hospital)
Written documentation of physician’s referral (must include the state license number, plan of treatment and estimated duration
PROSTHETIC DEVICES, APPLIANCES OR DURABLE MEDICAL EQUIPMENT:
Doctor’s orders or prescription
Pick-up and delivery points
Number of miles
BILLS MUST BE ITEMIZED:
ancelled checks, cash register receipts and non-itemized “balance due” statements cannot be processed. Each itemized bill must include:
Name and address of provider (doctor, hospital, laboratory, ambulance service, etc.)
Date of service
Amount charged for each service
MEMBER CLAIM FORM INSTRUCTIONS:
For services rendered in C
ease send claims to P.O. Box 60007, Los Angeles, CA 90060
out-of-state claims, pl
act Customer Service for the claims office address. Out-of-state claims must be sent to the Blue Plan
of the state in which services were rendered. For your convenience, the Customer Service number is listed on your Member ID card.
NOTE: If your coverage includes Prescription Drug benefits, call (800) 700-2533 for customer assistance.