Fill - Free fillable Pharmacy Services - Major Medical Member Submitted Claim (Blue Cross Blue Shield of North Dakota) PDF form

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. Request your pharmacist or pharmacy supplier to complete sections 2a, 2b and 2c

3. 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: Pharmacy Services Department

4510 13th Ave S

Fargo, ND 58121

4. Retain copies of all documents for your records

Physician/Provider/Supplier Instructions:

1. Complete sections 2a, 2b and 2c 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: Pharmacy Services Department

4510 13th Ave S

Fargo, ND 58121

Pharmacy Services - Major Medical Member

Submitted Claim Form

29318561 • 01-19

Section 1

Patient Information

Member ID

Patient Name

Address City State Zip Code

Birthdate (mm/dd/yyyy) Gender

o Male o Female

Is this a medication for an on-the-job injury? o Yes o No

Do you have other insurance for prescription medications?

o Yes o No

If yes, please provide name of other insurance:

Policy Number

Please include any pharmacy receipts related to this claim with this form.

Patient/Subscriber/Member or Legal Representative Signature

I certify that the information is correct and that the patient indicated above is eligible for beneﬁts. I have received

the medications described herein and authorize release of all information contained on this claim form to Blue Cross

Blue Shield North Dakota.

Signature Date (mm/dd/yyyy)

Section 2a

Pharmacy Information

Pharmacy Name

Address City State Zip Code

Section 2b

Prescription Claim Information

Original pharmacy receipts are required. Please submit receipts, itemized statements and proof of payment.

Was this prescription medication purchased outside the U.S.A.? o Yes o No

All ﬁelds below must be completed. (Example in Section 2c.) Call your pharmacist if you need assistance.

Claim 1

Rx Number Date Filled (mm/dd/yyyy)

Quantity Day Supply

Name of Medication

NDC Number (Your pharmacist can provide the NDC number identifying the drug.)

Prescribing Physician NPI Number

Prescription Cost

Amount Paid By Member

4510 13th Avenue South, Fargo, North Dakota 58121

Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association

Noridian Mutual Insurance Company

29318561 • 01-19

Page 1 of 2

Pharmacy Services - Major Medical Member

Submitted Claim Form

State

Prescription Claim Information

Claim 2

Rx Number Date Filled (mm/dd/yyyy)

Quantity Day Supply

Name of Medication

NDC Number (Your pharmacist can provide the NDC number identifying the drug.)

Prescribing Physician NPI Number

Prescription Cost

Amount Paid By Member

Claim 3

Rx Number Date Filled (mm/dd/yyyy)

Quantity Day Supply

Name of Medication

NDC Number (Your pharmacist can provide the NDC number identifying the drug.)

Prescribing Physician NPI Number

Prescription Cost

Amount Paid By Member

Section 2c

Example of How to Complete the Prescription Drug Claim Form

Rx Number

000006011481

Date Filled (mm/dd/yyyy)

01/12/2013

Quantity

Day Supply

Name of Medication

"Drug Name"

NDC Number (Your pharmacist can provide the NDC number identifying the drug.)

00123456731

Prescribing Physician NPI Number

9215241163

Prescription Cost

$205.14

Amount Paid By Member

$50.00

Is this prescription claim for a compound medication? o Ye s o No

Note: If yes, make sure your pharmacist completes the information below.

Compound Information

If a compound prescription, please enter all information per drug used.

Compound Prescriptions (For Pharmacy Use Only)

Rx # NDC Number Drug Ingredient Quantity Charge

29318561 • 01-19

Page 2 of 2

4510 13

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)

ﻣﻠﺣ وظﺔ: 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)

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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

’, 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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Pharmacy Services - Major Medical Member Submitted Claim (Blue Cross Blue Shield of North Dakota)

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