Fillable Member Medical Claim Form

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Member Medical Claim Form

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924639 10/2021
Member Medical Claim Form
COBRA***
NOTE: NALC HBP may disclose the information on this form to other persons and entities, including your employer (if your coverage is
through your employer). We may do this to process the claim or administer the health plan.
EFFECTIVE DATE OF COVERAGE
PRIMARY MEMBER INFORMATION: Primary Member complete this section
If yes, provide: NAME OF HEALTH INSURANCE COMPANY
X
POLICY NUMBER TYPE OF PLAN (HMO OR PPO) IF KNOWN
NO If yes, Name of Third Party: _____________________________________________________________________YES
NOYES
DISABLED***
STUDENT FULL-TIME
*** EFFECTIVE DATE
N/AEMPLOYED FULL-TIME
F. AT THE TIME MEDICAL SERVICE WAS PROVIDED WAS THE PATIENT:
If you answered Yes to D1 and/or D2 above, and the other insurance company is primary, then please send us this form and (a) a copy of the explanation of benefits
(EOB) and (b) the itemized bill(s) for this claim.
Mail Completed form to:
NALC Health Benefit Plan
Cigna Payer 62308
PO Box 188004
Chattanooga, TN 37422-8004
888-636-NALC (6252) or 703-729-4677
RETIRED***EMPLOYED
NOYES
NOYES
YYYYMM DD
YYYYMM DD
YYYYMM DD
( )
DATE
YYYYMM DD
If payment is due to my provider, I authorize NALC to make payment directly to the health care professional listed on the enclosed bills(s).
Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or
statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any
material fact thereto, commits a fraudulent insurance act which is a crime. For residents in the following states, please see the last page of
this form: Alaska, Arizona, California, Colorado, District of Columbia, Florida, Kentucky, Maryland, Minnesota, New Jersey, New Mexico, New
York, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas and Virginia.
I certify that the information supplied is true and correct.
B. DATE OF BIRTHA2. GENDER
YYYYMM DD
M F
OtherChild
M
F
Spouse
YYYYMM DD
NOYESNOYES
This form can be used to file all medical claims. It's not intended for pharmacy claims.**
**Please note: You only need to fill out this form if your health care professional isn't filing the claim for you.
Even if not part of the Cigna network (out-of-network), your health care professional can still file the claim for you.
We've added instructions on the back of this form to make it easy for you to complete.
A1. PRIMARY MEMBER’S NAME (Last Name)
(First Name) (M.I.)
C. PRIMARY MEMBER’S MAILING ADDRESS (No., Street)
(City) (State) (ZIP Code)
DAYTIME TELEPHONE #
D. NALC ID NUMBER
(on the front of your NALC ID card)
E. EMPLOYER NAME
F. PRIMARY CUSTOMER STATUS
PATIENT INFORMATION: Complete this section only if the patient is not the primary customer
D. GENDER
C. DATE OF BIRTHB. RELATIONSHIP TO PRIMARY CUSTOMER
(M.I.)(First Name)A. PATIENT’S NAME (Last Name)
E. PATIENT’S ADDRESS - IF DIFFERENT THAN PRIMARY CUSTOMER ADDRESS (No., Street)
(City) (ZIP Code) (State)
A. ACCIDENT OR ILLNESS
DUE TO EMPLOYMENT?
B. INJURY DUE TO
AUTO ACCIDENT?
C. DESCRIPTION OF HOW ACCIDENT OR WORK-RELATED ILLNESS/INJURY OCCURRED
D. DATE OF ACCIDENT OR BEGINNING OF ILLNESS E. ARE YOU OR YOUR DEPENDENTS FILING A CLAIM OR LAWSUIT AGAINST A THIRD PARTY INCLUDING AN INSURANCE COMPANY IN
ORDER TO RECOVER THE COST OF EXPENSES INCURRED AS A RESULT OF THIS ACCIDENT OR ILLNESS?
ACCIDENT/OCCUPATIONAL CLAIM INFORMATION:
Complete this section only if you are filing the claim because of an accident or occupational (work-related) illness or injury
FAMILY/OTHER COVERAGE INFORMATION:
Complete only if claim is for a dependent and/or other coverage is in effect
A. SPOUSE EMPLOYED? IF NO, HAS SPOUSE BEEN EMPLOYED
DURING LAST 12 MONTHS?
B. NAME OF SPOUSE (Last Name) (M.I.)(First Name)
SPOUSE'S DATE OF BIRTH
YYYYDDMM
C. NAME OF SPOUSE'S EMPLOYER
ADDRESS OF SPOUSE’S EMPLOYER (No., Street)
(ZIP Code) (State)
(City)
TELEPHONE #
( )
D1. IS THE PATIENT COVERED UNDER ANOTHER HEALTH INSURANCE PLAN?
D2. IS THE PATIENT COVERED UNDER MEDICARE?
NO
YES
CERTIFICATION
PRIMARY MEMBER'S SIGNATURE
PAYMENT INSTRUCTIONS
PRIMARY MEMBER'S SIGNATURE
YYYYDD
DATE
MM
X
CLEAR FORM
3.
4.
5.
6.
7.
10.
8.
EXPLANATION OF BENEFITS
Once we've processed the claim, you'll receive an Explanation of Benefits (EOB). The EOB will explain the charges applied to
your deductible (the amount you pay for covered services before your plan begins to pay) and any charges you owe your
health care professional. Please keep your EOB on file in case you need it in the future.
MAILING INSTRUCTIONS
- If you are sending one claim, please don't staple or paper clip the bills to the claim form.
- If you are sending more than one claim in the same envelope, then please use a paper clip to keep the claim form and
itemized bills together.
- Send your completed claim form and itemized bills to the address listed on your ID card.
If you have additional questions, please contact Customer Service using the toll-free number on your ID card.
INSTRUCTIONS FOR FILING A CLAIM
We suggest you make a copy of your bill(s) and your completed claim form for your records.
Important: We reserve the right to request other documents, such as medical records, if we need them before processing
your claim.
If the patient has other health insurance coverage, and that other insurance is primary and NALC secondary, we need an
Explanation of Benefits (EOB) for this service from the other insurance company when you send the completed form and
itemized bill.
9.
1.
2.
IMPORTANT
Use this form for all medical plans.
You only need to fill out this form if your health care professional isn't filing the claim for you. Even if not part of the Cigna
network (out-of-network), your health care professional can still file the claim for you.
If you received this claim form electronically, click to the right of the each field and type in the information. Once done,
remember to click on the Clear Fields button on the bottom of page 1 after printing out the completed form.
If you are filling the form out by hand, use a new printed form instead of a photocopy. That way we can scan your form
and process the claim with no delays. Please print clearly in black ink.
Please use a separate claim form for each health care professional, and for each member of your family. You can get a
new blank form by going to www.nalchbp.org
and clicking "Claim Forms" which is located under "Forms" in the "Member
Resources" tabs. You can also call Customer Service at 888-636-NALC (6252).
To process your claim, we need your member identification number (above in Primary Member Section, Block D). It's on
the front of your NALC ID card.
We need an itemized bill to process the claim correctly. We can't accept receipts, balance due statements and cancelled
checks in place of the itemized bill.
Itemized bills must include:
Primary member name
Date of Service (mm/dd/yyyy)
Patient name
Type of service/Procedure code
Charge for the service
Health care professional name/credentials
Health care professional address
Health care professional Tax ID number
Diagnosis code (ICD format)
11.
924639 10/2021
Alaska Residents: A person who knowingly and with intent to injure, defraud or deceive an insurance company or files a claim containing false,
incomplete or misleading information may be prosecuted under state law.
Arizona Residents: For your protection, Arizona law requires the following statement to appear on/with this form. Any person who knowingly presents
a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
California Residents: For your protection, California law requires the following to appear on/with this form. Any person who knowingly presents a
false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Colorado Residents: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose
of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for
the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds
shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
District of Columbia Residents: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the
insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information
materially related to a claim was provided by the applicant.
Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim
containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime.
Maryland Residents: Any person who knowingly OR willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly OR
willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and
civil penalties.
New Mexico Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material
thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5000 and the stated value of the
claim for each such violation.
Oregon Residents: Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance
or statement of claim containing any materially false information; or, (2) conceals for the purpose of misleading, information concerning any material
fact, may have committed a fraudulent insurance act.
Pennsylvania Residents: Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact
material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Tennessee Residents: 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, fines and denial of insurance benefits.
Texas Residents: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to
fines and confinement in state prison.
Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or
files a claim containing a false or deceptive statement may have violated state law.
IMPORTANT CLAIM NOTICE
Caution: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or
statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact
thereto, commits a fraudulent insurance act.
924639 10/2021
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Member Medical Claim Form

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Completed 22 November 2021

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