Fillable Member Submitted Claim Form Medical Services (Blue Cross Blue Shield of North Dakota)

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Member Submitted Claim Form Medical Services (Blue Cross Blue Shield of North Dakota)

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The Member Submitted Claim Form Medical Services (Blue Cross Blue Shield of North Dakota) form is 3 pages long and contains:

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  • 2 check-boxes
  • 129 other fields

Country of origin: US
File type: PDF

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NOTE: Incomplete claim forms will be returned and will delay the processing of the claim.
Member Instructions:
1. Complete section 1 and sign form
2. Ask your physician, healthcare provider or medical service supplier
to complete section 2
3. If any other health insurance made payment on the claim, please
include a copy of the Explanation of Benefits from that payer
4. Submit completed form (sections 1 and 2) along with any receipts,
itemized statements and proof of payment by:
• Fax: (701) 282-1888
• Mail: BCBSND
Attn: Medical Claims Department
4510 13th Ave S
Fargo, ND 58121
5. Retain copies of all documents for your records
Physician/Provider/Supplier Instructions:
1. Complete section 2 and sign form
2. Return completed form to:
• Patient or
• Blue Cross Blue Shield of North Dakota (BCBSND) by:
– Fax: (701) 282-1888
– Mail: BCBSND
Attn: Medical Claims Department
4510 13th Ave S
Fargo, ND 58121
Member Submitted Claim Form
Medical Services
29318540 • 6-17
Member Submitted Claim Form
Medical Services
Section 1
PICA
Patient Information
Patient’s Name
Address City State Zip Code
Phone Number Birthdate (mm/dd/yyyy)
Gender
o Male o Female
Relationship to Insured
o Self o Spouse o Child o Other
PICA
Insured Information
Insured’s ID Number
Insured’s Name
Address City State Zip Code
Phone Number
Patient’s or Authorized Person’s Signature
I authorize the release of any medical or other information necessary to process this claim.
Signature Date (mm/dd/yyyy)
Section 2
Physician or Supplier Information
Date of Accident (mm/dd/yyyy) Referring Physician NPI
For Local Use Only
Diagnosis Code
4510 13th Avenue South, Fargo, North Dakota 58121
29318540 • 6-17
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company
Page 1 of 2
State
State
Physician or Supplier Information
Date(s) of Service
Place of
Service
Procedure, Services
or Supplies (Explain
Unusual Circumstances)
Description of Services
Diagnosis
Pointer
Charges
Days
or Units
Rendering
Provider I.D.#
From
MM DD YY
To
MM DD YY
CPT/
HCPCS
Modifier
$
$
$
$
$
$
Federal Tax ID Number
o SSN o EIN
Patient’s Account Number Total Charge
$
Service Facility Location Information
Facility NPI
Billing Provider Information
Phone Number Billing NPI
Signature of Physician or Supplier Including Degrees or Credentials
Signature Date (mm/dd/yyyy)
Page 2 of 2
29318540 • 6-17
4510 13
th
Avenue South, Fargo, North Dakota 58121
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
29376608 11-18
Noridian Mutual Insurance Company
In accordance with federal regulations, Blue Cross Blue Shield of North Dakota is required to provide you the
following disclosure:
Blue Cross Blue Shield of North Dakota complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, gender identity, sexual orientation
or sex. Blue Cross Blue Shield of North Dakota does not exclude people or treat them differently because of
race, color, national origin, age, disability, gender identity, sexual orientation or sex.
Blue Cross Blue Shield of North Dakota:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, please call Member Services at 1-844-363-8457 (toll-free) or through the
North Dakota Relay at 1-800-366-6888 or 711.
If you believe that Blue Cross Blue Shield of North Dakota has failed to provide these services or discriminated
in another way on the basis of race, color, national origin, age, disability, gender identity, sexual orientation
or sex, you can file a grievance with:
Civil Rights Coordinator
4510 13th Ave S
Fargo, ND 58121
701-297-1638 or North Dakota Relay at 800-366-6888 or 711
701-282-1804 (fax)
CivilRightsCoordinator@bcbsnd.com (email) (Communication by unencrypted email presents a risk.)
You can file a grievance in person or by mail, fax, or email within 180 days of the date of the alleged
discrimination. Grievance forms are available at http://www.bcbsnd.com/report or by calling 1-844-363-8457.
If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil
Rights electronically through the Office for Civil Rights Complaint Portal, available
at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW.
Room 509F, HHH Building
Washington, DC 20201
800-368-1019 or 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Español (Spanish)
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-844-363-8457 (TTY: 1-800-366-6888 o 711).
Deutsch (German)
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung. Rufnummer: 1-844-363-8457 (TTY: 1-800-366-6888 oder 711).
中文 (Chinese)
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-844-363-8457（TTY：1-800-366-6888 或
711）。
Oroomiffa (Oromo)
XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa
1-844-363-8457 (TTY: 1-800-366-6888 ykn 711).
Tiếng Việt (Vietnamese)
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.
Gọi số 1-844-363-8457 (TTY: 1-800-366-6888 hoặc 711).
Ikirundi (Bantu – Kirundi)
ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu.
Woterefona 1-844-363-8457 (TTY: 1-800-366-6888 canke 711).
اﻟﻌرﺑﯾﺔ (Arabic)
ﻣﻠﺣوظﺔ: إذا ﻛﻧت ﺗﺗﺣدث اذﻛر ا ﻟ ﻠﻐﺔ، ﻓﺈن ﺧدﻣﺎت ا ﻟﻣ ﺳﺎﻋدة ا ﻟ ﻠﻐوﯾﺔ ﺗﺗواﻓر ﻟك ﺑﺎ ﻟﻣ ﺟﺎن. ا ﺗﺻل ﺑرﻗم
844-363-8457-1 )رﻗ م ھ ﺎ ﺗف ا ﻟﺻم و ا ﻟ ﺑ ﻛم :
1-800-366-6888 أو 711(.
Kiswahili (Swahili)
KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo.
Piga simu 1-844-363-8457 (TTY: 1-800-366-6888 au 711).
Русский (Russian)
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.
Звоните 1-844-363-8457 (телетайп: 1-800-366-6888 или 711).
日本語
(Japanese)
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-844-363-8457
（TTY: 1-800-366-6888 または 711）まで、お電話にてご連絡ください。
नेपाल& (Nepali)
!यान %दन
ु
होस
्
: तपाइ/ले नेपाल2 बो4न
ु
ह
ु
5छ भने तपाइ/को 9नि;त भाषा सहायता सेवाह> 9नःश
ु
4क >पमा उपलCध छ । फोन गन
ु
Hहोस
्
1-844-363-8457 (%ट%टवाइ: 1-800-366-6888 वा 711) ।
Français (French)
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.
Appelez le 1-844-363-8457 (ATS : 1-800-366-6888 ou 711).
한국어 (Korean)
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-844-363-8457
(TTY: 1-800-366-6888 또는 711)번으로 전화해 주십시오.
Tagalog (Tagalog – Filipino)
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad. Tumawag sa 1-844-363-8457 (TTY: 1-800-366-6888 o 711).
Norsk (Norwegian)
MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 1-844-363-8457
(TTY: 1-800-366-6888 eller 711).
Diné Bizaad (Navajo)
Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dę
́
ę
́
’, t’áá jiik’eh, éí ná hólǫ
́
,
kojį’ hódíílnih 1-844-363-8457 (TTY: 1-800-366-6888 éí doodagó 711.)
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Member Submitted Claim Form Medical Services (Blue Cross Blue Shield of North Dakota)

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Completed 10 June 2021

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